Despite a wealth of technological advances, we all still spend more time charting than we’d like. But what if you looked at charting as something other than a chore?


Instead of seeing it as one more thing to cross off your to-do list, what if you considered it a vital means of communication? After all, isn’t that the original purpose of charting?


In medicine, we need to conspire or collaborate more. When different healthcare providers act together in harmony, patients will more likely be satisfied, rather than confused—and if something goes wrong and we all end up in court together, we’ll be less likely to have helped the plaintiff’s attorney.


Why will patients be more satisfied? The reason is simple. If everyone tells a patient something different, she doesn’t know whom to trust and gets confused.

 

Here’s an example. A patient comes in with cough and shortness of breath. The ER nurse does her assessment and tells the patient it’s probably a virus, but that she needs a chest x-ray to be sure. Then the ER doctor comes in, does her assessment and tells the patient it’s probably a virus and she doesn’t need a chest x-ray or any antibiotics.


Two days later, she’s not better and goes to her doctor, who tells her she has bronchitis but doesn’t need an x-ray, and writes her a prescription for antibiotics. If she’s in the top fifth percentile for IQ, she’ll probably realize that differences of opinion are not uncommon in certain conditions. If she’s like the other 95 percent of your patients, she’ll probably be confused and assume that two of the three people who gave her advice are incompetent. If only everyone had acted in harmony, the patient might have instead been satisfied and content while the virus ran its course and she recovered completely.


Nurse Rebekah: Most of us want to be the expert at something in our lives. Some people just pretend like they’re experts on everything—which we all know is totally implausible. (My hubby calls these people “Mr. SMITH,” which stands for Smartest Man In The Hemisphere. Try that on your next know-it-all…it’s hilarious.) But many people spend the majority of their lives honing their craft, knowledge and career. Whether you’re a working nurse or doctor, a Starbucks employee or an electrician, at some point you’ll probably know more than other people who may or may not be in your field, and your advice will be sought out. Therefore, because people are seeking your advice, you should make sure you know what you’re talking about—and if you DON’T know what you’re talking about, heed my mother’s advice to “keep your pie hole shut.”


I say this because patients look to us for guidance about their health. Sure, they may have had a prior appointment with Dr. Google, but they’re looking for your professional opinion. Stick to the facts. Using Dr. Brady’s example, I might say, “Mrs. Smith, because of your cough and fever, I’m going to order a chest x-ray per our protocol to expedite your care in the emergency room. The doctor will look at it and tell you what he thinks.” Leave it at that. Don’t claim virus or bacteria—because unless you brought your microscope with you, you won’t be able to defend that claim. And the physician should have the foresight to look in the chart and not say, “Oh, I don’t need a chest x-ray…why did that silly nurse order that?” Don’t staff-split. Leave that to the psych patients and four-year-olds.


Starting to get the idea? Only say—and write—exactly what you observe. Anything more is just speculation and can confuse and frustrate both patients and staff.

"More:ERChartingSoapsAssessments

When it comes to nurse's notes most student nurses are up in arms on exactly what they should be writing. A focal note should be one of the easiest tasks to chart, but many students still find themselves struggling. There are different styles when it comes to writing nurses notes and you will eventually come to find a method that better suits your needs or department.

SOAP (ER) format is a common used style for nurse's notes because they are easy to understand by all medical staff. The (ER) is also included but not always applied.

Subjective Data: This section of the nurse's note should include a description of your patient based on what your patient has told you.

Example: Pain Assessment, Data that pertains to verbal statements that cannot be collected during a physical finding.

Objective Date: This section of the nurse's note should include all your physical findings during your head to toe assessment or your focal assessments.

Example: Vital signs, Edema, wounds, etc.

Assessment; Including Nurses Diagnosis: This would be the nurse's interpretation of your patients condition. Including your Nursing diagnosis based on the medical diagnosis the doctor has provided.

Plan: This will include the follow up you did based on your findings above.

Example: Treatments and Tests

Education: Any patient teaching would be explained here in your nurses notes, did you explain to your patient about their medications, use handouts, or give special instructions?

Return: Here you will include any follow up instructions or what your patient will need to look for based on their diagnosis.

DAR nursing notes are very commonly used for Focus Charting. They are simple and easy to follow.

Data: This area will include your subjective and objective information. In this area of your nurses note you will support the problem or describe any observations made at a specific time in your patients treatment.

Action: This area will include all actions you take to care for your patients. You will also include any type of evaluations or changes made to present care of your patient.

Response: Included in this area will be a description of your patients response to any of the care you have provided. As an example if you raised the head of bed because your patient has a complaint of shortness of breath you would chart this and also explain if your treatment was effective or ineffective. If your treatment was ineffective you would then chart any other treatments you tried and if the patient's doctor was notified.

A nurse's note is a legal document and should be treated in the outmost professional way. Your nurse's note should be factual and not contain any sort of opinion. Always remember if you did not chart it, it did not happen. So always take credit for the work you do on any patient and make sure everything is charted.

Legal Implications of Documentation

The client health-care record is an important legal document. It provides information that

shows care has been provided, and it can be used to resolve questions or concerns about

accountability and the provision of care. Documentation provides a chronological record

of the many events involving a client from admission to discharge and may be used to

refresh the RN’s memory if they are required to give evidence in court. It is very

common for the courts to use clinical documents to reconstruct events, establish times

and dates, and resolve conflict in testimony.

A lawyer representing an RN will often rely on available documentation to establish that

the care provided by the RN was reasonable and prudent. Similarly, a client’s lawyer may

use the same documentation to try and show that the RN failed to meet the standard of a

reasonable and prudent care provider

Quality documentation provides specific information (who, what, how and why) about

the actual care the registered nurse provided and a record of the client’s response to that

care. It assists others in confirming that the RN’s care was competent and safe, met

acceptable standards and procedures, was provided in a timely manner, and was

consistent with organization policies. When determining if certain information should be

included within a heath-care record, applicable facility policy should be consulted.

GUIDELINES FOR DOCUMENTATION

The following guidelines provide expectations and suggestions to assist RNs in achieving

complete and accurate documentation of client care within any setting. They are

organized according to twelve topic areas commonly seen in published material regarding

nursing documentation.

1. Objective/Factual Documentation

Registered nurses must document accurately, completely, and objectively including any

errors that occurred. An objective description is the result of direct observation and

measurement. This means it should contain descriptive, objective information about what

the registered nurse sees, hears, feels and smells. Registered nurses document relevant

information related to client care but do not record opinions or assumptions. If something

is not documented, it could be challenged or assumed that it was not done.

It is important that RNs document all information thoroughly, including what was done

and what was observed. For example, if a client was suctioned, the documentation would

include why the client needed suctioning, what the outcome was, and the client’s

response to suctioning. Registered nurses must record clearly, legibly and accurately and

use appropriate terminology. Use a consistent format that follows documentation policies

and procedures, as well as forms that are specific to each practice setting. Take credit for

care given and sign completely using first initial, full legal surname and designation. In

some practice settings policies may allow the use of initials, but only if they can be

uniquely linked to an individual care provider.

Correct spelling and the use of exact measurements ensures that a health-care record is

accurate and demonstrates a level of competency and attention to detail on the part of the

RN. Because health-care records reflect accountability for the care provided, registered

nurses should document their own observations and actions only.

2. Timeliness

Documentation is enhanced when client information is entered frequently into the client

health-care record (Keatings & Smith, 2000). Contemporaneous documentation, defined

as the completion of the health-care record notes as close to the time of care as possible,

enhances the credibility and accuracy of health-care records. Documentation of an

intervention should never be completed before it takes place.

Documentation in chronological succession assists in revealing a change pattern in a

client’s health status. Information must be entered on the health-care record e' In the practice setting

policies will guide the RN in how late entries are to be documented.

The frequency of documentation and amount of detail documented are dictated by a

number of factors including:

• facility/agency policies and procedures

• the complexity of the health problems

• the degree to which the client’s condition puts them at risk

• the degree of risk involved in the treatment or care

 

While agency policies regarding documentation should be followed to maintain a

reasonable, prudent standard of documentation, recording of nursing care provided

should be more comprehensive, in depth and frequent if the client is very ill, has unstable

health-care needs and unpredictable outcomes

7. Recording Medication Administration

Document the administration of medications immediately after its administration. This

prevents errors such as another RN administering medication when the first dose was not

recorded. The document Medication Administration:

Guidelines

RNs should only record medications they have administered

themselves. The practice setting policy should be explicit if exceptions are permitted,

under what circumstances, and the process to be followed.

The RN should also document in the health-care record additional pertinent information

related to the process of administering medications (i.e., self-administration, client

questions, client refusal of medication), related interventions (i.e., client education,

communication with a prescriber) and outcomes of care (i.e., therapeutic drug response,

side effects). Registered nurses must also comply with relevant documentation

requirements arising from legislation such as the Controlled Drugs and Substances Act,

as well as practice setting policies.

8. Recording Assistance with Care

In most circumstances, when a RN assists another RN in providing care (e.g., when

assisting another RN to ambulate a patient or insert an IV), the RN providing care

documents the actions and the client’s responses and notes that another care provider

assisted. It is not required to name the person who assisted. In certain circumstances, as in

a critical incident such as a fall, it is important to record the names of those individuals

assisting.

9. Designated Recorder in Emergency Situations

In some emergency situations (e.g., during a cardiac arrest), documentation may be done

by a designated recorder. When acting as a designated recorder, the recorder identifies

the persons involved and the care they provided. The practice setting policies need to

provide guidance and support for how a designated recorder should document and

identify the forms that are to be used.

10. Clarification of Orders

If an order is poorly written, never guess or rely on group consensus to interpret that

order. Always call the writer for clarification. There is a high risk for error and potential

for an unsafe event to occur. A written record of every telephone call should be

maintained, whether it is with another care provider for clarification of orders, or with a

client following discharge from your facility or unit.

11. Recording a Telephone Conversation with a Client

When advice is given by telephone, the RN is relying on the client’s own assessment of

the situation. The RN does not have the benefit of examination and objective findings.

The health-care record should include the date (including year) and time of the call, the

nature of the call, the response by the RN,

12. Interactions with other Health-care Professionals

It is the RN’s responsibility when developing care plans, documenting on flow sheets,

completing narrative or computerized documentation, or participating in team or family

conferences, to document in the health-care record the outcomes or agreed upon plans of

action and the names of the people involved. All health-care professionals are responsible

for documenting the care they provide or the actions taken. The system used should

record all interactions with members of the health-care team, including clarification of

orders, failed attempts to reach other team members, and the follow up action taken.

These interactions may involve different formats such as person-to-person, telephone,

video-conferencing or other electronic means, and the documentation may use many

different tools and forms.

 

9

PART 3: DOCUMENTATION SYSTEMS AND METHODS

Multiple documentation systems have emerged in recent years in response to changes in

health-care delivery, and advanced technology has affected the expectations for

documentation2. Regardless of the documentation system used, meticulous and accurate

documentation is necessary to meet the obligations of registered nursing practice while

minimizing legal involvement due to inaccurate or incomplete documentation.

E-health Records

There is no doubt that the computerization of the health-care record has many benefits.

The same principles apply whether documentation is completed in the paper health-care

record or electronically. “Online documentation is defined as a technology that automates

the capture of clinical care data. In the nursing realm, this can include assessment data,

clinical findings, and nursing plans of care, nursing interventions (along with results),

patient’s progress toward goals, critical pathways, medication administration, risk

assessments, discharge planning, patient education and more” ( . The practice setting must have clear policies and guidelines to address issues

related to electronic documentation.

E-health Record Security

Electronic documentation systems require security features that protect client

confidentiality and that prevent others from modifying documentation entries. Once

documentation is completed, the program should lock entries so that they become “read

only” information.

The practice setting policies should reference that staff should only have access to healthcare

records of clients in their specific area of practice. Select staff may be given

authority to access all health-care records.

To heighten security of passwords, they should be required to be changed at specific

intervals of time. The level of access to the e-health record is connected to the username.

The RN should use only his or her own password or access card when gaining access

to the e-health record. This ensures that the computer log will accurately reflect that a

particular RN made the entry.

When a practice setting has two systems for documentation (paper and electronic)

continuity of care must be maintained. E-health records must identify when paper-based

health-care records are also being used, and in the event that a paper health-care record is

used during an electronic system failure, the electronic health-care record must direct the

reader to the paper health-care record. The care provider must sign documentation in an

e-health record. Electronic signatures are valid, provided that they are used to

demonstrate accountability and are accessible only to the person identified by that

signature 

Incorrect entries must be corrected, indicating who made the correction and when. The

RN needs to know how to correct documentation errors on the e-health record  ;

 10

to the policies of the practice setting. As with any documentation method, data that have

been part of the health-care record are not deleted.

For e-health record changes or additions, the RN should refer to their employer’s policy

and follow the process detailed in such policies (CNO, 2004). Making any entry into the

health-care record must be voluntary. Late entries should be clearly marked as a late

entry. Any alterations, corrections or deletions to the e-health record should be carefully

documented, dated (including the hour) and properly signed by the RN who is making

additions to the file. As with a paper file, an alteration to the documentation of another

care practitioner is not permitted.

Methods of Documentation

SOAP/IER

One of the most prominent features of this problem-orientated method of documentation

is the structured way in which narrative progress notes are written by all health-care team

members, using the SOAP, SOAPIE or SOAPIER format.

Subjective the client’s observations

Objective the care provider’s observations and tests

Assessment the care provider’s understanding of the problem

Plans goals, action, advice

11

Intervention when an intervention was identified and changed to meet

client’s needs

Evaluation how outcomes of care are evaluated

Revision when changes to the original problem come from revised

interventions, outcomes of care or time lines this is used to

denote changes

PIE

The PIE notes are numbered or labeled according to the client’s problems. Resolved

problems are dropped from daily documentation after the RN’s review. Continuing

problems are documented daily 

Problem

Intervention

Evaluation

Graphic Sheets and Flow Sheets

Health-care record entries should reflect the most recent assessment, as they are done, to

ensure treatment decisions are based on accurate information. If documenting on a flow

sheet or checklist, checkmarks may be used as long as it is clear who performed the

assessment or intervention. The meaning of the checkmark or symbol used must be

identified in the practice setting policy. If an intervention that is listed on the flow sheet is

not applicable in the care provided for a client, do not leave it blank, but indicate as such

by the use of “N/A” in this space. Make narrative nursing notes when needed

SUMMARY

In summary, regardless of the method used, registered nurses are responsible and

accountable for documenting client care including assessments, interventions carried out,

and results of the interventions on client outcomes. Clients who are very ill, considered

high risk or have complex health-care needs require more comprehensive, in depth and