📋 Learn the top 8 nursing documentation methods. Discover key reporting types. Understand essential do’s and don’ts to ensure accurate medical records and patient safety.

Methods and Systems of Documentation in Nursing

What is Nursing Documentation? Nursing documentation is a crucial part of patient care that ensures accuracy, completeness, and legal compliance. It records patient conditions, treatments, and responses, helping in clinical decision-making and continuity of care.

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Types of Nursing Documentation Methods

1. Narrative Charting

• Traditional method using a story format
• Documents patient condition, interventions, and responses
• Useful in emergency situations
• Lacks a structured format, making it time-consuming

2. Source-Oriented Charting

• Each healthcare team member maintains separate records
• Easy to locate discipline-specific information
• Disadvantage: Patient data is scattered, making retrieval difficult

3. Problem-Oriented Charting (POMR)

• Developed by Dr. Lawrence Weed
• Organizes records based on patient problems
• Promotes collaboration between healthcare professionals
• Uses SOAP/SOAPIE Format:
  • S: Subjective Data
  • O: Objective Data
  • A: Assessment
  • P: Plan
  • I: Intervention
  • E: Evaluation

4. PIE Charting (Problem, Intervention, Evaluation)

• Focuses on ongoing nursing care
• Eliminates the need for a separate care plan
• Uses flow sheets for 24-hour documentation
• Disadvantage: Nurses must review entire notes to determine patient status

5. Focus Charting (DAR Format)

• Emphasizes patient-centered care
• Uses DAR Format:
  • D: Data
  • A: Action
  • R: Response
• Organizes progress notes effectively

6. Charting by Exception (CBE)

• Only abnormal findings are documented
• Uses flow sheets for standard assessments
• Saves time but may lead to missing important details

7. Computerized Documentation

• Uses Electronic Health Records (EHR) for real-time updates
• Ensures quick data retrieval and efficient care planning
• Reduces paperwork and enhances accuracy

8. Case Management with Critical Pathways

• Focuses on cost-effective and high-quality care
• Uses a multidisciplinary approach to achieve expected patient outcomes
• Reduces hospital stays and improves coordination

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Guidelines for Documentation

General Principles

Documentation should be:

• Accurate, relevant, and consistent
• Clear, concise, and complete
• Legible and readable (whether handwritten or electronic)
• Logical, timely, and sequential
• Patient-centered

Content of Documentation

• Include the patient’s perception of their condition and their response to interventions.
• Document symptoms using the patient’s own words.
• Include actual nursing care, such as education, physical, and psychosocial support.
• Record vital signs, changes in condition, medications, treatments, interventions, and reassessments.
• Document all patient teaching (preoperative, postoperative, and discharge instructions) and who was present.
• Provide an objective clinical judgment of the nurse.
• Record only what is seen and heard directly from the patient.
• If information is obtained from others, document the source (e.g., “Family member stated…”).

Legal Considerations

• Each page must include the patient’s name and medical record number.
• All entries must be signed, time-stamped, and dated.
• Use an original signature with full name and title (or electronic signature in EHR systems).
• Include the date, month, year, and time for all documentation. Use am/pm or military time. This is important during adverse events. It is also crucial when notifying another caregiver.
• Incorrect entries must be clearly identified and corrected.
• Only the nurse performing the intervention should document it at the time of or close to the intervention.
• Use approved abbreviations and standardized terminology.
• Chart in chronological order, avoiding gaps.
• Create separate entries for each narrative item.
• Late or omitted notes should be added as a new entry with a notation.
• Do not backdate or alter previous notes.

Formatting and Writing Standards

• Use appropriate forms (if no EHR is available).
• Fill out forms completely.
• Mark non-applicable fields with “N/A”.
• Use blue or black ink (if handwritten) that cannot be erased.
• Do not use pencil, felt-tip markers, or ink that fades/bleeds.
• Never erase, use correction fluid, or obscure errors.
• To correct an error, draw a single line through the incorrect entry, initial, and date it. Enter the correct information above or in a new note.
• Be familiar with electronic health record (EHR) correction procedures.

Adverse Event Documentation

• Carefully document adverse events using an objective description of observations, assessments, interventions, and follow-up care.
• Include patient/family statements and information given to them.
• If an incident report was filed, do not reference it in the patient’s chart.
• Document interventions performed, who was notified, and the resolution of the problem.

Special Documentation Cases

• If an interpreter is used, document their name and the patient’s approval.
• Accurately document patient refusal or non-compliance with treatment.
• Document all telephone interactions, including time, date, content, and advice given.
• Always document baseline mental status.
• Assess and document patient condition at discharge or transfer.
• Record discussions with the patient and family about treatment, progress, and self-care.

Prohibited Documentation Practices

• Do not disagree with another caregiver in the chart.
• Avoid words like accidentally, assume, confusing, may be, mistake, unexpectedly, appeared, apparently.
• Never document medications before administering them.
• Never document an abnormal finding without documenting the intervention and patient response.
• Do not document for another healthcare provider.
• Do not correct or destroy another clinician’s notes.
• Verbal orders should be co-signed by the provider.

Do’s and Don’ts of Documentation

Do’s

✅ Record in chronological order and complete notes at the time care was given. ✅ Ensure the correct chart is being used before entering information. ✅ Use complete descriptions and correct grammar. ✅ Write objectively, specifically, and factually. ✅ Sign each entry with professional signature. ✅ Record phone calls with physicians, including time and response. ✅ Chart precautions and preventative measures. ✅ Note late entries clearly with date and time.

Don’ts

❌ Do not backdate, tamper with, or add to past notes. ❌ Do not write in margins. ❌ Avoid shorthand or non-approved abbreviations. ❌ Do not make relative statements (e.g., “wound is healing”—instead, describe the wound). ❌ Do not wait until end of shift to chart. ❌ Never chart for someone else. ❌ Do not erase or obliterate errors. ❌ Avoid assumptions or subjective language. ❌ Do not leave blank spaces in documentation. ❌ Never use a signature stamp. ❌ Never alter a patient’s record—this is a criminal offense. ❌ Do not write imprecise descriptions (e.g., “bed soaked”—quantify it). ❌ Do not chart excuses (e.g., “medication not given because it wasn’t available”). ❌ Never chart ahead of time.

Principles of Good Record Keeping

1. Be factual, consistent, and accurate.
2. Update records promptly.
3. Ensure clarity and legibility.
4. Document in a way that text cannot be erased.
5. Entries should be dated, timed, and signed.
6. Draw a clear line through errors, initial, and date them.
7. Avoid slang, jargon, and abbreviations that are not universally recognized.
8. Store records securely and follow institutional policies on retention and destruction.
9. Ensure patient identification on every page.
10. Ensure documentation remains legible even when photocopied or scanned.

Features of Good Nursing Documentation and Recording

1. Concise: Use brief, clear statements instead of complete sentences. Begin each entry with a capital letter and end with a period.
2. Permanence or Proper Usage of Ink: Use a ball pen for writing on the chart. Avoid using felt pens or pencils.
3. Accuracy: Document only factual information regarding patient care. Avoid personal opinions or interpretations. Use proper punctuation marks when quoting the patient’s statements.
4. Appropriateness: Record only relevant and essential information in the chart.
5. Comprehensiveness and Correct Order: Entries should be continuous and uninterrupted. If extending to another line, it must be at a new time entry.
6. Use of Standard Terminologies: Always use approved standard abbreviations and medical terminologies in documentation.
7. Properly Signed: Include the full name, status, and signature of the healthcare provider in every entry.
8. Legible Handwriting: Ensure handwriting is clear and readable for other healthcare professionals.
9. Do Not Leave Spaces: Draw horizontal lines through empty spaces to prevent unauthorized additions to nurse’s notes.
10. Confidentiality: Maintain patient privacy by ensuring that all documented information remains confidential.

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Legal Guidelines for Documentation/Recording

Patient records may be required as legal evidence in court or for professional inquiries. Nurses must be diligent and precise when documenting to fulfill both professional and legal responsibilities.

1. Each patient record must contain complete and accurate identification details.
2. Document all investigations and treatment procedures accurately, and retain original reports.
3. Do not erase, use correction fluid, or scratch out errors. Avoid making retaliatory or critical comments about the patient or other healthcare professionals.
4. Obtain informed consent from the patient or family for routine treatment and surgery.
5. Correct all errors promptly by drawing a single line through the error and initialing it.
6. Record all factual information appropriately.
7. Do not leave blank spaces in nurse’s notes.
8. Use legible handwriting and black ink for entries.
9. If an order is questioned, document that clarification was sought.
10. Avoid vague phrases like “status unchanged” or “had a good day.”
11. Begin each entry with the date and time, and end with your signature and title.
12. For electronic documentation, keep passwords confidential.
13. All entries must be signed by the person making them.
14. Maintain chronological order in records, including date and time.
15. Use only standard abbreviations approved by the institution.

REPORTING: CHANGE-OF-SHIFT REPORTS, TRANSFER REPORTS, INCIDENT REPORTS

Introduction to Reports

Reports are an effective means of communication among healthcare team members, providing orientation and information about patients. They can be written or oral. They help in documenting the patient’s current condition. They also cover inpatient and outpatient services and changes in treatment outcomes. Reports are typically prepared daily, weekly, monthly, or annually.

Criteria for Writing Good Reports

1. Promptness: Reports should be given promptly to serve their intended purpose, such as during shift changes.
2. Clarity and Conciseness: Reports should be clear, concise, legible, and complete.
3. Accuracy and Organization: Include complete data with date, time, procedure details, and results.
4. Patient Transfers: New admissions and transfers must be recorded properly.
5. Signature Requirement: The nurse writing the report must sign it.

Types of Reports

Reports should be provided promptly and should be well-organized for easy understanding. The two main types of reports are:

1. Oral Reports

• Given when immediate use is required but not for permanent records.
• Examples: Reports given by a nurse to the relieving nurse, charge nurse, or doctor.
• Must be clearly expressed and presented in an engaging manner.

2. Written Reports

• Used for information that needs to be accessed by multiple personnel and retained for reference.
• Examples: Day and night reports, interdepartmental reports, and other specific reports based on events or conditions.

Types of Reports in a Hospital Setting

Reporting is crucial for verbal or written communication regarding patient status, treatment, and outcomes. It ensures continuity of care and coordination among healthcare providers.

1. Change-of-Shift Report

• Provided by an outgoing nurse to the incoming nurse to ensure continuity of patient care.
• Also known as the end-of-shift report.
• Can be delivered orally or in written form.
• Includes patient’s current health status, physician’s orders, medications, IV fluids, diet, and activity levels.
• Key Points:
  • Provide only essential background information.
  • Identify the patient’s nursing diagnosis and healthcare problems.
  • Review ongoing discharge plans.
  • Relay significant changes in therapies and evaluate the results of medical care.
  • Prioritize urgent tasks for the incoming staff.

2. Transfer Report

• Required when a patient is moved from one unit to another for different levels of care.
• Ensures continuity of care during the transfer.
• Can be given via phone or in person.
• Key Information to Include:
  • Patient’s name, age, gender, primary physician, medical diagnosis, and any surgeries performed.
  • Summary of progress up to the time of transfer.
  • Current health status, including physical, physiological, and psychosocial aspects.
  • Ongoing treatment plan.
  • Special precautions such as isolation.
  • Required medical equipment (e.g., ventilator, tracheostomy care).

3. Incident Reports

• A formal record of unexpected events, accidents, or injuries occurring in a healthcare facility.
• Completed by the involved staff or a witness.
• Used for quality improvement and legal protection.
• Key Points for Writing an Incident Report:
  • Record date, time, and location of the incident.
  • The nurse who witnessed or discovered the event should complete the report.
  • Provide an objective, factual description of what happened.
  • Include the patient’s condition at the time and any measures taken by healthcare professionals.
  • Avoid interpretations, explanations, or assigning blame.
  • Submit the report as soon as possible.
  • Maintain a written account of the incident.

4. Legal Reports

• Includes incident reports, accident reports, complaints, and documentation related to negligence claims.
• Used when a hospital faces legal scrutiny due to alleged poor care or negligence.
• Must be brief, objective, and contain all pertinent information.
• Key Guidelines:
  • Maintain accuracy, timeliness, and completeness.
  • Ensure reports are relevant to the issue being addressed.
  • Document all details precisely to avoid misinterpretation.

Factors to be Considered in Record Keeping and Reporting

1. Fact: Information about clients and their care must be functional. A record should contain descriptive, objective information about what a nurse sees, hears, feels, and smells. Similarly, any events occurring in the management of affairs within an institution or hospital should be documented accurately. Managers should ensure that records contain functional information to avoid misleading interpretations and administrative errors.
2. Accuracy: A client record must be reliable. The information must be accurate so that others can confidently rely on it. The use of correct measurements and precise documentation ensures the reliability and trustworthiness of the records.
3. Completeness: A recorded entry or report should be concise yet thorough. It must contain all necessary information about a client, student, staff member, or event taking place in the organization. Incomplete records can lead to misunderstandings and ineffective decision-making.
4. Currentness: Delays in recording and reporting can result in serious consequences and unnecessary delays in taking action. A late entry in a chart may be interpreted as negligence. Timely documentation is essential to ensure efficiency and accuracy in patient care and institutional operations.
5. Organization: Information should be well-structured and presented logically. Organize records clearly and chronologically. This approach enhances understanding. It ensures information is easy to retrieve when needed.
6. Confidentiality: The person responsible for recording information is legally and ethically obligated to maintain confidentiality. All collected data must be kept secure. It should be shared only with authorized personnel. This practice protects the privacy of clients and ensures compliance with ethical and legal standards.

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COURSES

GNM

BSC NURSING