records

1. DOCUMENTATION

2. • Documentation and reporting
• · Documentation – purposes of reports and records
• · Confidentiality
• · Types of client records/common record keeping forms
• · Methods/systems of documentation/recording
• Guidelines for documentation
• · Do‘s and don‘ts of documentation/legal
• · Reporting – change of shift reports,
• Transfer reports, incident reports

3. • DOCUMENTATION serves as a permanent record of client information and care.
• Reporting takes place when two or more people share information about client care, either face
to face or by telephone

4. PURPOSES
• Communication. Provides efficient and effective method of sharing information.
• Legal documentation. It is admissible as evidence in a court of law.
• Research. Provides valuable health-related data for research.
• Statistics. Provides statistical information that can be utilized for planning people’s future needs.
• Education. Serves as an educational tool for students in health discipline.

5. • Audit & quality assurance. Monitors the quality of care received by the client and the competence
of health care givers.
• Planning client care. Provides data which the entire health team uses to plan care for the client.
• Reimbursement. Provides the basis for decisions regarding care to be provided and subsequent
reimbursement to the agency, to cover health-related expenses

6. TYPES OF RECORD
• Source oriented medical record
• Each person or department makes notations in a separate section/s of the client’s chart.
• Most traditional
• Different disciplines chart on separate forms
• each reader must consult various parts of the record to get a complete picture
• Records become bulky

7. NARRATIVE CHARTING ( TRADITIONAL CLIENT RECORD )
• ▫ Most flexible of all methods and is usable in any clinical setting.
• • Five basic components of a traditional client record
• admission sheet
• physician’s order sheet
• medical history
• nurse’s notes
• special records and reports (referrals, x-ray, reports, laboratory findings, report of surgery, anest hesia
record, flowsheets, vital signs I&O, medications)

8. PROBLEM-ORIENTED MEDICAL RECORD
(POMR OR POR)
• The record integrates all data about the problem, gathered by the members of the health team.
• Four basic components of POMR /POR
• database.
• Problem list.
• Initial list of orders or care plans.
• Progress notes:
Nurse’s or narrative notes (SOAPIE format) subjective, objective, analysis, planning, intervention, evaluation
• ◦ flow sheets (data that are monitored)
• ◦ discharge notes or referral summaries

9. • METHODS (STYLES) OF CHARTING

10. A. NURSE’S OR NARRATIVE NOTES (SOAPIE
FORMAT)
• S-subjective. What pt tells you.
• 0 – objective. What you observe, see.
• A – assessment. What you think is going on based on your data.
• P – . plan what you are going to do. Can add to better reflect nursing process
• i – intervention (specific interventions implemented)
• e – evaluation. Pt response to interventions.
• R – revision. Changes in treatment.

11. B. PIE CHARTING
• Similar to SOAP charting
• both are problem-oriented
• PIE comes from the nursing process, SOAP comes from a medical model.
• P-problem
• i-intervention
• e-evaluation ex:
• p#1 risk for trauma related to dizziness. •
IP#1 instructed to call for assistance when getting OOB. Call light in reach.
• EP#1 consistently call for assistance before getting OOB. Continues to experience dizziness.

12. C. FOCUS CHARTING
• Uses narrative documentation (dar)
• data – subjective or objective that supports the focus (concern)
• action – nursing intervention
• response – pt response to intervention
Ex:
• D – complaining of pain at incision site , ps: 7/10
• A – repositioned for comfort. Demerol 50mg im given.
• R – states a decrease in pain, “feels much better.”

13. D. COMPUTERIZED CHARTING
• Password. Never share or change frequently.
• Legible
• can be voice-activated, touch-activated.
• Date and time automatically recorded.
• Abbreviations and terms are selected by a menu provided by the facility.
• Terminals are usually easily accessible, in pt rooms, convenient hallway locations.
• Make sure terminal cannot be viewed by unauthorized persons.

14. KARDEX
• Provides a concise method of organizing and recording data about a client, making information
readily accessible to all members of the health team
• It is a series of flip cards usually kept in portable file
• it is a way to ensure continuity of care from one shift to another and from one day to the next
• It is a tool for change – of – shift report. But endorsement is not simply reciting content of
kardex. Health care needs of the client is still primary basis for endoresement.

15. CONTD…
• Usually include the ff. Data:
– personal data
– basic needs
– allergies
– diagnostic tests
– Daily nursing procedures
– medications and intravenous (IV) therapy, blood transfusions
– treatments like oxygen therapy, steam inhalation, suctioning, change of dressings, mechanical
ventilation.
• Entries usually written in pencil. This implies the kardex is for planning ang communication
purpose only.

16. General Documentation Guidelines
• Ensure that you have the correct client record or chart.
• Document as soon as the client encounter is concluded to ensure accurate recall of data.
• Date and time of each entry.
• Sign each entry with your full legal name and with your professional credentials.
• Do not leave space in between entries.
• If an error is made while documenting, use a single line to cross out the error, then date, time and sign
the correction
• Never change another person’s entry even if it is incorrect
• Use quotation marks to indicate direct client responses.
• Document in chronological order
• Use permanent ink
• document all telephone calls that you received that are related to client’s case.

17. Characterstics of Good Recording
Brevity
• Entries are concise
• Complete sentences are not required
• Start each entry with a capital letter and end the entry with a period even if the entry is a single word
or phrase.
Use ink/permanence
• Avoid pencil for permanence of data, because the client’s chart can be used as an evidence in a legal
court.

18. CONTD…
Accuracy
• chart objective facts, not your interpretations or opinions
Eg.
• Ate 50% of the food served not ate with poor appetite.
• Refused medications not uncooperative.
• Seen crying not depressed.

19. • Place complaint of the client in quotation marks to indicate that it is his statement. “Chest pain
radiating down the left arm”
• objective data are also to be charted.
E.G. Skin cold and clammy. Diaphoretic. Prefers to sit up. Vital signs taken as follows: temp-37.6C,
PR-110/min., RR-26/min. BP-140/90 mmhg.
• Describe behaviors rather than feelings to allow other health team members to determine the
actual problems of the client.
• Refusal of medications and treatments must be documented.

20. CONTD…
Appropriateness
• only information that pertains to the client’s health problems and care are recorded.
• Any other personal information that is conveyed to the nurse is appropriate for the record.

21. CONTD…
Completeness and chronology/organization/sequence/timing.
• Notes should appear on each succeeding line
• Continuous charting is done for each entry unless a time change occurs. No need for a new line for each new
idea or entry.
• Date is entered in the date column on the first line of every page of nurse’s notes and whenever the date
changes.
• Time is entered in the time column whenever a new time entry occurs.
• Avoid time changes in the text of nurse’s notes.
• Avoid double chart. If something appears on a particular sheet, it does not need to appear on the nurse’s
notes, unless there is an alternation from the normal, e.G. Body temperature, blood pressure.
• Avoid squeezing information to a space because you forgot to chart it earlier. Add the information on the
first available line. Write the time the event occurred, not the time you entered the information.

22. • The following information should be charted:
Physician’s visits.
Times the patient leaves and returns to the unit, mode of transportation and destination.
Medications should be charted immediately after administration. O treatments should be charted immediately
after being done.
Use of standard terminology
Use only those abbreviations and symbols approved by the institution; spell correctly, use proper grammar.
Signed.
Affix signature, place at the end of charting, at the right hand margin of the nurse’s notes. Sign each entry with
your full name and status, e.g. SN for student nurse, RN for registered nurse. Script, not printing is used for the
signature.

23. • Confidentiality
Only the health personnel who participate in the care of the client are allowed to read the chart.
• Legal awareness
Chart only what you personally have done, observe, heard, smelled, or felt.
Do not discard any of the client record.
• Legible
Writing must be clear and easily read by others
If writing is not legible, then print.
A horizontal line drawn to fill up a partial line. This is to prevent other persons from adding information
in the nurse’s notes.
Eg. Needs attended. Referred accordingly.-------Ma. Tosca cybil torres, RN, MAN

24. REPORTING
• Takes place when two or more people share information about client care , either face to face or
by telephone.
Types of reporting
• Walk in rounds
• change – of – shift reports or endorsement – for continuity of care – it is based on health care
needs of the client – it is not mere reciting the content of the kardex

25. Telephone reports
Provide clear accurate and concise information
the nurse documents telephone report by including the following information:
• when the call was made
• who made the call/report
• who was called
• to whom information was given
• what information was given
•what information was received

26. • Telephone orders
• only RN’s may receive telephone orders
• the order need to be verified by reporting it clearly and precisely.
• The order should be countersigned by the physician who made the order within the prescribed period of
time (within 24 hours)
transfer reports – this is done when transferring a client from unit to another.
Incident reports or occurrence reports – used to document any unusual occurrence or accident in the
delivery of client care

27. GROUP ACTIVITY SITUATION :
• Antonioayo farmer was , 55 / , found by his son lying on the floor unconscious.
• He was brough to the ER and was diagnosed with CVA probably, bleeding he is then admitted to the medical ICU
for continuity of critical care he is drowsy, restless at times severely , dyspneic and wit h excessive, secretins
• Crackles are heard upon auscultation at both lower lung fields .
• Vital Signs
• B P . / : 19 0 /110 , 3 9 , m m H g
• T ° 39°C
• Respiratory Rate 38 per minute ,
• Pulse Rate 112 bats per minute