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How to choose the right words when charting
Before you chart something that may be critical, consider conspiring with the rest of your team. I’m not saying you should lie. You are obligated to tell the truth, but you get to decide how you will tell the truth. If you and the doctor think your patient with a URI and chest pain may actually have a pulmonary embolism, chart “pleuritic chest pain” and the CT scan is justified—and if there is a complication from the contrast, everyone is vindicated.
If, like most people with a URI and chest pain, she really has just a painful cough, chart “painful cough” instead of “pleuritic chest pain” and send her home. If three months later she really does have a blood clot and you all land in court, the consistent, harmonious charting will likely get the case dropped.
One more example: If a mom says her child is lethargic, but the child looks fine, chart “less playful” rather than “lethargic.” That’s what the mom means. She doesn’t mean “I can’t keep my child awake,” which is the medical definition of lethargy.
Again, you shouldn’t lie, but if you spend a little time conspiring or collaborating with the doctor and explaining things to your patient, you might accomplish many things that would make both your mother and President Obama proud: less unnecessary testing, lower medical costs, more realistic patient expectations, few medicolegal lawsuits and hopefully happier, healthier and more trusting patients. Perhaps if we are breathing in harmony, work could even become more harmonious.
Nurse Rebekah: Harmonious! Sounds like yoga to me! Relaxing and very zen-like. However, when it comes to charting and documentation, I just try to be as objective as possible. For instance: “Patient complains of severe nausea and is currently eating chips in triage.” That uses the patient’s own words but paints a pretty clear (and objective) picture of what is really going on.
Try at all costs to take the bias out of your charting. If your chart looks biased, a lawyer can always say to a jury, “Look, Nurse Child wrote that this patient stank and was rude. She didn’t even like this patient, so how could she have taken good care of him?” That will make you look like Nurse Ratched.
Instead, you can always chart: “Patient stood up on gurney and urinated into sink while calling staff ‘ugly, stupid, dirty gigolos.’” The patient just painted his own picture as a real jerk.
Healthy work environments and healthy communication styles go hand in hand. In the super technology-laden world that we live and work in today, we can take care of many, many patients, all at the same time. This can come at the expense of face time with our colleagues. So strike a downward-dog pose, breathe and collaborate. Maybe even light a candle to relax as you conspire away.
Got it? Conspiring with your colleagues is a good thing. So choose your words carefully, communicate your concerns and expect an increasingly harmonious environment.
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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.
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The one thing nurses should never assume about charting
How many times have you heard the phrase “If it wasn’t charted, it wasn’t done?” Simply writing your observations, concerns and actions in the chart, however, isn’t enough to guarantee good care.
: The example I gave for the benign, self-limiting condition commonly known as a cold or a “URI.” But what if the patient in our vignette had something more sinister? What if it was a TIA, and two days later the patient had a stroke and did not have a complete recovery? What if the nurse documented that the patient had transient vision loss in addition to her chief complaint of arm numbness? What if the patient assumed the nurse told this to the doctor but didn’t? What if the patient was sent home, but returned two days later with a completed stroke, and the next doctor who saw her told her she should have never been sent home from her first visit two days prior?
What would this patient think? Whom would she blame for her bad outcome? What if she sued? What would her lawyer think if he looked over the medical records and saw that there were multiple inconsistencies between the documentation of the different doctors and nurses involved in her care?
I’ll tell you what that lawyer would think: “Cha-ching! No evidence of conspiracy in this chart.” The only thing left would be for the malpractice insurers to write the check.
Nurse Rebekah: There is always the risk of being human. Not everyone presents with the textbook symptoms (I really wish patients would!) and not everyone is on his A-game every single day. So we should never assume that the left hand knows what the right hand is doing. (Ever hear the old adage about assuming?!)
If you’re really concerned as a patient, nurse or physician, it never hurts to simply reiterate important information or ideas. I have irritated many a doctor by reminding them of stuff (as in turn, they have irritated me), but if I save a life three of those times a doctor got irritated—well then, mission accomplished.
Never, ever assume that charting a concern is the same as drawing it to a physician’s attention. As important as good charting is—and we’ll talk about that more in Part III of our charting essentials series—patient advocacy always comes first. If you’re worried about your patient, tell someone. You can always chart it later.
Let’s review: Charting is all about communication, and communication is absolutely essential to good patient care. As good as you may be—and we don’t doubt that you’re an excellent nurse—you can’t do it alone. To meet and exceed patient expectations, healthcare providers have to work in harmony with one another
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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.
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DOCUMENTATION GUIDELINES FOR
Quality documentation and reporting are necessary to enhance efficient, individualized
Regardless of the format used to
document, the client1’s health-care record is a formal, legal document that details a
client’s care and progress. Differences in how client health-care records are kept exist
across the multiple settings in which registered nurses (RNs) practice, and each client
care population has its own unique characteristics and expectations. Still, the
foundational principles of nursing documentation apply to every type of documentation
in every practice setting.
Documentation is not separate from care and it is not optional. It is an integral part of
registered nurse practice, and an important tool that RNs use to ensure high-quality client
care. The term “documentation” as used in these guidelines refers to:
any written or electronically generated information about a client that
describes client status or the care or services provided to that client.
The purpose of this document is to provide guidance to RNs that will assist them in
producing clear, accurate and comprehensive accounts of client care within any setting.
PURPOSES OF DOCUMENTATION
Communicating and Providing Continuity of Care
The health-care record is, first and foremost, a clinical document. It should include
information to identify the client, the care provider, the date of the encounter, the
problem(s) being addressed, care provided, the clinical reasoning for the choice of care,
the client’s response and/or outcome of the interventions and future plans. Effective
written communication skills are essential in order to precisely document each of these
components of nursing practice. When done well, nursing documentation is a valuable
tool to support effective communication between providers and continuity of care within
and across settings. A good test to evaluate whether a client’s health-care record is a
satisfactory clinical document is to answer the following question: “If another RN had to
step in to care for the client because the assigned RN was not available, does the healthcare
record provide sufficient information for the seamless delivery of safe, competent
and ethical care to the client?”
In Alberta, RNs are required to adhere to the Canadian Nurses Association (CNA) Code
of Ethics for Registered Nurses and the CARNA Nursing Practice Standards. They have
a responsibility to apply nursing knowledge and skill in providing safe, competent,
ethical care A registered nurse’s professional practice with respect to
documentation should reflect such safe, competent nursing care.
Registered nurses are responsible for their own nursing practice, and documentation is a
part of that responsibility. Comprehensive and accurate documentation provides a record
of astute nursing insights, reflects the excellence of holistic nursing care, and provides a
health-care record of the professional and personal support that RNs provide every day to
clients and their families. The RN’s documentation may be used in legal proceedings.
Complete, accurate and thorough nursing documentation provides evidence that the RN
has met the requirements expected in the role in a particular practice setting.
Registered nurses must document the care they provide. Documentation on the client
record is an indication of the care provided to the client and makes RN care visible.
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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.
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Providing Quality Improvement and Risk Management
The client information contained in the health-care record is often a tool used within
quality improvement processes to evaluate services provided and outcomes achieved. In
fact, the Canadian Council of Health Services Accreditation (CCHSA) sets standards for
client documentation, which must be met by facilities as part of their accreditation
process. Comprehensive, accurate documentation provides a sound basis for appropriate
measurement of the quality of care and facilitates the evaluation of the client’s progress
toward preferred outcomes.
A risk-management program is a system to identify, assess and reduce risks to clients,
visitors, staff and organizational assets. Good risk-management practice requires clear
documentation, as health-care records are used for audits and ongoing risk management
. “The nurses’ notes are risk-management and quality assurance
tools for the employer and the individual nurse”
documentation is ultimately good risk management for the client receiving care, for the
staff providing the care, and for the organization.
Facilitating Evidence-Based Practice
Evidence-based practice is supported and informed by research findings, as well as by the
depth and breadth of knowledge and experience of registered nurses. The health-care
record can be an important source of data for nursing and health research and, for this
purpose, accurate and thorough documentation is essential. The documentation by the RN
provides a rich source of information related to nursing interventions and evaluation of
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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
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.
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
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3. Use of Space
Documentation must not have empty lines or spaces, and the time when assessments and
interventions were completed must be noted. On forms or flow sheets every required
space should be filled. “Not applicable” or “N/A” should be noted rather than leaving a
4. Use of Abbreviations
Registered nurses need to know what, if any, abbreviations are acceptable in their agency.
Many organizations are currently developing policies that are aimed at reducing the
number of common but preventable sources of errors. These policies are related to
approved or prohibited abbreviations, or are policies requiring that no abbreviations be
used in a practice setting. The Institute for Safe Medication Practices (ISMP)
has developed a list of error-prone abbreviations
Document any follow-up of assessments, observations or interventions that have been
done, including whether a physician or other care provider has been notified regarding
the client. Failed attempts to reach a physician or other care provider, the follow-up
action taken, and the client’s response to interventions should be documented on the
client’s health-care record.
6. Correcting Errors
To correct an error in a paper-based health-care records system, one method that can be
used to appropriately make corrections is the SLIDE rule
is completed as follows: cross through the word(s) with a single line, and insert your
initials, along with the date and time the correction is made; then enter the correct
information/explanation. Some agencies require that the correction is highlighted by
using an arrow or asterisk. Check the agency/facility policy for the accepted means of
correcting errors, as some require that words such as
documentation error”, “error”, “mistaken entry” and “void” are included with your
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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:
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
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.
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13. Client Education
Documentation of educational interventions requires knowledge and skills that are
complex and comprehensive. Registered nurses perform, on a daily basis, a broad scope
and depth of client education. Inadequate or incomplete documentation of client
education impedes communication among health-care providers about what has been
taught and diminishes the aspect of this component of care provided by the registered
When documenting and evaluating client education, it is important to define the extent of
the client’s understanding , as cited
“Teaching was done related to infection. Client accurately described the signs and
symptoms of infection and reported accurately that if any of these develop, he would call
his primary care provider.”
The RN needs to consider the following when documenting client education:
• Document each formal (planned education) as well as informal (unplanned)
• Written education entries should include:
o a brief description of the material taught
o the method(s) used for teaching (e.g., written, visual, verbal, auditory, and
instructional aides used)
o the involvement of and the interaction between client and family in the
teaching/learning process, and evaluation of the teaching objectives with
validation of client comprehension and learning
o timed and signed entry
• Incorporate follow-up education requirements.
14. Documenting an Incident in the Health-care Record
When an incident occurs, pertinent data should be documented on the health-care records
of the client(s) involved in the incident. However, the names of other clients should not
be recorded in another’s health-care record. These names should be documented on an
incident/occurrence report. The purposes of a health-care record and an
incident/occurrence report differ. The client health-care record is a record of events
directly related to the client. Do not document “refer to incident/occurrence report” in
the client health-care record. The policy of the practice setting should clearly describe
the process of completing an incident/occurrence report.
An incident report provides a description of an unexpected or unusual event, for example,
a client fall, medication error or harm to clients, staff or visitors. Careful documentation
of incidents is important for continuous quality improvement, learning from mistakes and
managing risk, and in case of a complaint or legal action. The following suggestions
provide guidance on how to complete documentation regarding an incident:
• Be concise, accurate and objective.
• Record what was seen, and describe the care provided, who else was involved and
the client’s (person’s) condition.
• Do not try to guess or explain what happened (e.g., the RN should record that side
rails were not in place, but should not write that this was the reason the client fell
out of bed).
• Record the actions taken by other health-care providers at the time.
• Do not blame individuals in the documentation.
• Always record the full facts.
Discuss with the manager and other team members what would be classified as a critical
incident and what should be documented in the health-care record and on an incident
report. The RN must take time to plan what they will enter into the health-care record
prior to the actual entry. This can help prevent the recording of opinion and the drawing
of conclusions that should be avoided in the health-care record.
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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.
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
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
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 ;
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
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Narrative documentation is the traditional method for recording nursing care provided. It
is a story-like format to document information specific to client conditions and nursing
care. Data are recorded in the progress notes without an organizing framework. It often
requires the reader to sort through information to locate the data required.
Problem-Orientated Medical Record (POMR)
The foundation of this method is a single list of client problems generated by members of
the health-care team. The nursing process forms the basis for the POMR method of
documenting client problems. the advantages of this method of
documenting as follows:
• gives emphasis to client’s perceptions of their problems
• requires continuous evaluation and revision of the care plan
• provides greater continuity of care among health-care team members
• enhances effective communication among health-care team members
• increases efficiency in gathering data
• provides easy-to-read information in chronological order
• reinforces use of the nursing process
The chronological problem number is not repeated within the same hospitalization. When
the problem is resolved, the list is modified by signing a space or check off area next to
the listing. The date that the problem was resolved is noted next to the signature. There is
usually another form for narrative progress notes
frequent documentation by the registered nurse providing care.
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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
Intervention when an intervention was identified and changed to meet
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
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
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Focus Charting (sometimes referred to as DAR)
This method of documentation consists of notes that include data, both subjective and
objective; action or nursing interventions; and response of the client. One distinction of
focus documentation is its movement away from documenting only problems. Instead,
the notes are structured according to client concerns:
• a sign or symptom
• a condition
• a nursing diagnosis
• a behavior
• a significant event
• a change in a client’s condition
Documentation is written in accordance with the nursing process. Registered nurses are
encouraged to broaden their thinking to include any client concerns, not just problem
areas, and the critical thinking process is utilized. Focus documentation is easily
understood by caregivers and is adaptable to most health-care settings. This approach
helps promote effective documentation (Lampe, as quoted in
Charting by Exception (CBE)
This system of health-care recording assessments, interventions, and responses was
developed to eliminate redundancy and to organize information in a manner that would
reduce errors in documentation. When used following a thorough orientation to the
guidelines and protocols established for nursing assessment and intervention, CBE can:
• save time
• reduce repetition of documentation
• provide immediate identification of significant changes in a client’s condition
However, in the presence of unclear nursing guidelines or lacking other flow sheets that
are needed for recording other care or treatments, CBE can be more prone to legal
interpretation of a breach in standards in nursing care. If standard care is given using
CBE for documentation, then notations are not needed. A check mark and signature is the
only identification that the standard of care was met. The exceptions to the norm must be
recorded. A RN utilizing this method of documentation must be consistent in
documenting the exceptions. Thorough and detailed descriptions of what happens to
clients, actions taken and outcomes are essential. The practice of alternating between
CBE and narrative notation is only applicable when an exception to the norm occurs.
Key elements required for CBE are:
• practice setting documentation policies and protocols
• assessment norms, standards of care
• individualized care plans
• unique flow sheets
• bedside accessibility of documentation forms
it is not acceptable to use documentation by exception unless these exist
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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
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