Documenting and Reporting

Reference

Berman, A., Snyder, S., Frandsen, G. (2021). Documenting and Reporting. In Kozier & Erb’s Fundamentals of Nursing Concepts, Process and Practice (11th ed., pp. 259-281). Pearson Education

Effective communication among health professionals is vital to the quality of client care. Generally, health personnel communication through discussion, reports, and records:

1. Discussion: an informed oral consideration of a subject by two or more healthcare personnel to identify a problem or establish strategies to resolve a problem.
2. Report: an oral, written, or computer-based communication intended to convey information to others. For instance, nurses always report on clients at the end of a hospital work shift.
3. Records, also known as charts or client records, are formal, legal documents that provides evidence of a client’s care and can be written or computer based. Although health organizations use different systems have different forms for documentation, all client records have similar information. The process of making an entry on a client record is called recording, charting, or documenting.

Characterisics of a Clien Record (JCI)

Timely, Complete, Accurate, Confidential, Specific to the client

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Ethical and Legal Considerations

American Nurses Association Code of Ethics, revised in 2015, Provision 3 states, “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.” This provision focuses on confidentiality. It is imperative in nursing that any client information be maintained as an obligatory secret. Access is limited to health professionals involved in giving care to the client.

• While the hospital is the rightful owner of the client’s record, the client maintains the same rights to the same records.

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Purposes of Client Records

1. Communication: the record serves as the vehicle by which different health professionals who interact with a client communicate with each other. This prevents fragmentation, repetition, and delays in client care.
2. Planning Client Care: data from the client’s record is used to plan or evaluate care for that client.
3. Auditing Health Agencies: a review of client records for quality assurance purposes, such as accreditation by the Joint Commission
4. Research: the information contained in a record can be a valuable source of data for research. The treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients.
5. Education: students in health disciplines often use client records as educational tools. A record can frequently provide a comprehensive view of the client, the illness, effective treatment strategies, and factors that affect the outcome of the illness.
6. Reimbursement: clinical records contain the relevant diagnoses and care provisions that are checked by insurance and government agencies as basis for reimbursement to the facility.
7. Legal Documentation: the record is usually admissible in court as evidence. In some jurisdictions, however, the record is considered inadmissible as evidence when the client objects, because information the client gives to the primary care provider is confidential.
8. Healthcare Analysis: information from records may assist in healthcare planners to identify agency needs, such as overutilized and underutilized hospital services.

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Documentation Systems

1. Source-oriented Record: the traditional client record where each healthcare provider makes notations in separate sections of the client’s chart, i.e., the admissions department has an admission sheet; the primary care provider has a physician’s order form, physician’s history sheet, and progress notes; nurses use the nurse’s notes.
   • Narrative charting is a traditional part of source-oriented records. These include routine care, normal findings, and client problems. There is no right or wrong order to the information, although chronological order is frequently used. The nursing process (“ADPIE”) may be used as a guideline for narrative charting.
   • Source-oriented records are convenient because care providers from each discipline can easily locate their respective forms on which to record and trace data relevant to one’s discipline.
   • A major disadvantage of a source-oriented record is the dispersion of data about a client’s problems throughout the various parts of the chart. A high level of communication between all healthcare disciplines involved in care is required for this type of chart.
2. Problem-oriented Medical Record (POMR): client data is arranged according to the problems the client has rather than the source of the information. Each problem will have its database, problem list, plan of care, and progress notes.
   • POMRs encourage collaboration and orients the caregivers to the client’s needs and makes it easier to track the status of each problem.
   • Disadvantages arise with the level of competency of each caregiver in filling out the problem-oriented chart, and constant vigilance to maintain an up-to-date problem list. Another problem arises with the need to duplicate entries for assessment and interventions that tackle multiple problems at once.
   • For progress notes, the SOAP(IER) format is often used: (a) subjective data, (b) objective data, (c) assessment (i.e., the statement of the problem), (d) plan, (e) interventions, (f) evaluation, (g) revision. Alternative formulations of this acronym can be AP, APIE, or APIER.
3. Problems-Interventions-Evaluation (PIE) documentation model groups information into three categories. It consists of a client care assessment flow sheet and progress notes. The flow sheet is a structured, specific assessment criteria such as human needs or functional health patterns. After assessment, the nurse establishes and records specific problems on the progress notes, often using nursing diagnoses to word the problem.
   • This charting method eliminates the traditional care plan and incorporates an ongoing care plan into the progress notes. However, this means that the nurse must review all the nursing notes before giving care to determine which problems are current and which interventions were effective.
4. Focus Charting (FDAR) is intended to make the client and client concerns and strengths the focus of care. Three columns for recording are often used:date and time, focus, and progress notes. In each entry, it is not necessary to have all three categories (DAR).
   • The focus may be a condition, a nursing diagnosis, a behavior, a sign or symptom, an acute change in the client’s condition, or a client strength.
   • The progress notes are organized into (D) data, (A) action, and (R) response.
   • The data segment reflects the assessment phase of the nursing process and consists of observations and data from flow sheets. Both subjective and objective data are recorded.
   • The action segment reflects planning and implementation and includes immediate and future nursing actions. t may also include any changes to the plan of care.
   • The response segment reflects the evaluation phase and describes the client’s response to any nursing and medical care.

Date/Hour	Focus		Progress Notes
2/11/20 0900	Pain	D	Guarding abdominal incision. Facial grimacing Rates pain at “8” on scale of 0-10
		A	Administered morphine sulfate 4 mg IV.
0930		R	Rates pain at “1.” States willing to ambulate.

5. Charting by Exception (CBE) is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. There are three key elements: flow sheets, which reflect patient status; standards of nursing care, which delineate normal from abnormal; and bedside to chart forms to allow immediate recording and to eliminate the need to transcribe data from the nurse’s worksheet to the permanent record.
   • In the provision of routine care (e.g., oral care q4h for unconscious patients), the nurse only needs to place a checkmark on the routine standard box. When variances arise, narrative charting is done on the progress notes to chart the exception.
   • Many nurses believe in the saying “not charted, not done” and subsequently may feel uncomfortable with the CBT documentation system. However, the nurses may circumvent this by placing “N/A” on flow sheets where the items are not applicable and to not leave blank spaces.
   • Charting by exception naturally does not maintain an extensive record and a full picture of the client’s health-related needs. This can leave nurses and the hospital at risk of malpractice or negligence litigation.
6. Computerized Documentation: the integration of all pertinent client information into one record. Computer terminals at bedside, or small handheld terminals may be used to document care immediately after it is given. Multiple flow sheets are no longer required due to the ease of access to various information in many formats. In charting, the nurse can either select from a list of standard terms or phrases or type out a narrative record.
   • Select disadvantages include: (a) client privacy may be breached if inadequate security measures are put in place, (b) software for electronic records are expensive, (c) system outages and breakdowns may occur, rendering data inaccessible, and (d) training may be required for each new system update.
7. Case Management model emphasizes quality, cost-effective care delivered within an established length of stay. This model uses a multidisciplinary approach to planning and documenting client care, using critical pathways. These forms identify the outcomes that certain groups of clients are expected to achieve on each day of care, along with the interventions necessary for each day.
   • Because expected outcomes and interventions are set in place, progress notes typically take on some type of CBE; a variance (expected goal that was not met) the deviates from what was planning on the critical pathway. The nurse notes these variances documenting the unexpected event, the cause, and actions taken to correct the situation or justify the actions.
   • Critical pathways are used for specific populations and client problems. Clients with multiple diagnoses and highly individualized needs or those with an unpredictable course of symptoms are difficult to document on a critical path.

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Documenting Nursing Activities

The client record should describe the client’s ongoing status and reflect the full range of the nursing process. Regardless of the records system used in an agency, nurses document evidence of the nursing process on a variety of forms throughout the clinical record.

1. Admission Nursing Assessment: a comprehensive admission assessment, also known as the initial database, nursing history, or nursing assessment, is completed when the client is admitted to the nursing unit.
2. Nursing Care Plans: the Joint Commission requires that the client record include evidence of client assessments, nursing diagnoses and client needs, nursing interventions, client outcomes, and evidence of a current nursing care plan. Care plans may be traditional, i.e., written for each client, or standardized. Standardized care plans were developed to save documentation time. These are based on an institution’s standards of practice, thereby helping to provide a high quality of nursing care. However, the nurse still makes an effort to individualize the plan to adequately address individual client needs.
3. Kardexes: the Kardex is a widely used, concise method of organizing and recording data about a client, making information quickly accessible to all health professionals. The system consists of a series of cards kept in a portable index file or on computer-generated forms. The card for a particular client can be quickly accessed to reveal specific data. In some organizations it is a temporary worksheet written in pencil for ease in recording frequent changes in details of a client’s care. This includes: pertinent information about the client, list of medications, list of intravenous fluids, list of daily treatments and procedures, list of ordered diagnostic procedures, etc.
4. Flow Sheets: a record for tabulating nursing data quickly and concisely over time. Some examples include:
   • Graphic Records, such as vital signs and client weight
   • Intake and Output Records, covering all routes of fluid intake and loss or output
   • Medication Administration Records (MARs)
   • Skin Assessment Record
5. Progress Notes: information about assessment and reassessment of the client’s problems and nursing interventions. The format for these notes vary, as shown in the discussion earlier.
6. Nursing Discharge and Referral Summaries: a discharge note and referral summary are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required. These include instructions for care, the final progress note, and checklists to facilitate data recording. Resolved health problems, continuing health problems, continuing treatments, current medications, lifestyle restrictions, comfort level, support networks, client education, discharge destination, and referral services are among the platitude of information that may be included in these summaries.

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General Guidelines for Recording

1. Date and Time: document the date and time of each recording. This is essential not only for legal reasons but also for client safety. Record the time in the conventional manner (12-hour clock) or military time (24-hour clock).
2. Timing: frequency of documentation according to agency and client condition. If possible, documentation should be done as soon as possible after assessment and intervention.
3. Legibility: all entries must be legible and easy to read to prevent interpretation errors. Hand printing or easily understood handwriting is usually permissible.
4. Permanence: all entries are made in dark ink so that the record is permanent and changes can be identified. Dark ink produces well on microfilm and in duplication processes. Agency policies about the type of pen and ink used for recording should be followed.
5. Accepted Terminology: only recognized and standard terminology should be used, especially with abbreviations. The Joint Commission developed National Patient Safety Goals (NPSGs) to combat patient injury related to such errors.
   • The official “Do Not Use” list includes U, instead written as unit; IU, instead written as international unit; Q.D. and Q.O.D. because these may be interchanged, instead written as daily and every other day respectively; unnecessary trailing zeroes (5.0) and missing leading zeroes (0.1); and MS when referring to morphine sulfate and MSO4, instead writing their full names.
6. Correct Spelling: the nurse must confirm any unsure spelling of words and names, specially for medications.
7. Signatures: entry signatures follow agency protocol. The signature normally includes the name and title of the person signing the record. Nurses can use their initials. With computerized charting, entries are often automatically attributed to the user account being used to enter data.
8. Accuracy:
   • Identification: the client’s name and identifying information should be stamped or written on each page of the clinical record. Extra care is needed when multiple patients share the same last name.
   • Documenting Notations: accuracy in notations involve recording facts or observations rather than opinions or interpretations.
   • Statements should be recorded verbatim and written as such.
   • Specificity: ambiguous words such as large or small are avoided. Instead, measurements should be expressed as “2 cm by 3 cm bruise”, for example.
   • Errors: mistakes should be eliminated with a single line and identified as erroneous with the nurse’s initials or name above or near the line (depending on agency policy). The original entry must remain visible.
   • Empty Space: blank spaces left after notation should be obstructed with a line so that no additional information can be recorded at any other time.
9. Sequence: events are normally documented chronologically, e.g., assessment, intervention, then response. Problems are updated or deleted as necessary.
10. Appropriateness: only pertinent information should be recorded. Other personal information or disclosures not relevant to the client’s care should not be recorded.
11. Completeness: the information that is recorded should be complete and helpful to the client and healthcare professionals.
12. Conciseness: recordings need to be complete yet brief to save time in communication. Each thought is ended with a period. Complete sentence structure is not necessary as the information is known to refer to the client, e.g., “Perspiring profusely. Respirations shallow, 28/min.”
13. Legal Prudence: accurate, complete documentation should give legal protection to the nurse, the client’s other caregivers, the healthcare facility, and the client. It provides proof of the quality of care given to a client. It is viewed as the best evidence of what really happened to the client.

Documentation Dos and Don'ts

• Chart a change in a client’s condition and show that follow-up actions were taken.
• Read the nurse’s notes prior to care to determine if there has been a change in the client’s condition.
• Be timely. A late entry is better than no entry; however, the longer the period of time between actual care and charting, the greater the suspicion.
• Use objective, specific, and factual descriptions.
• Correct charting errors.
• Chart all teaching.
• Record the client’s actual words by putting quotes around the words.
• Chart the client’s response to interventions.
• Review your notes. Are they clear and do they reflect what you want to say?
• Do not leave a blank space for a colleague to chart later.
• Do not chart in advance of the event.
• Do not use vague terms such as “appears to be comfortable”, and “had a good night”.
• Do not chart for another care provider.
• Do not alter a record even if requested by a superior or a primary care provider.
• Record assumptions or words reflecting bias or judgment (e.g., “complainer”, “disagreeable”).

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Reporting

Reporting is done to communicate specific information to an individual or group of people. A report, whether oral or written, should be concise, including pertinent information but no extraneous detail. In addition to change-of-shift reports and telephone reports, reporting can also include the sharing of information or ideas with colleagues and other health professionals about some aspect of a client’s care. Examples include the care plan conference and nursing rounds.

1. Change-of-Shift Reports: handoff communication, where the client’s care is communicated. Handoffs occur at many levels in the healthcare setting. For example, the admission of the client to the emergency department then to intensive care or other hospital division requires a handoff from nurse to nurse, nurse to physician, physician to physician, and ultimately to other healthcare providers.
   • Handoff Communication can take many forms— I PASS the BATON (Introduction, Patient, Assessment, Situation, Safety Concerns, Background, Actions, Timing, ownership, Next), I-SBAR (Introduction, Situation, Background, Assessment, Recommendation), PACE (Patient/Problem, Assessment/Actions, Continuing [treatments]/Changes, Evaluation), and Five P’s (Patient, Plan, Purpose, Problem, Precautions, Physician)
2. Telephone Reports: health professionals frequently report about a client by telephone. Nurses inform primary care providers about a change in a client’s condition; a radiologist reports the results of an x-ray study; a nurse may report to a nurse on another unit about a transferred client.
   • The nurse receiving a telephone report should document the date and time, the name of the individual giving the information, and the subject of the information received, and sign the notation. Outgoing telephone reports should also be documented by the nurse in the same manner.
   • Individuals receiving information via telephone should repeat information back to the sender to ensure accuracy.
   • The SBAR format is also commonly used in telephone reports.
3. Telephone and Verbal Orders: orders for therapy for a client by telephone or verbally is common. All orders should follow specific agency policies about telephone and verbal orders.
   • While the order is given, the nurse must write the complete order down on the physician’s order form and read it back to the primary care provider to ensure accuracy. Any order that appears ambiguous, unusual, or contraindicated by the client’s condition should be questioned. The written order should be indicated as a telephone or verbal order (TO, VO).
4. Care Plan Conference: a meeting of a group of nurses to discuss possible solutions to certain problems of a client. Other health professionals may be invited to attend the conference to offer their expertise.
5. Nursing Rounds: two or more nurses visit selected clients to obtain information that will help plan nursing care, provide clients the opportunity to discuss their care, and evaluate the nursing care the client has received.