Nursing Documentation Fundamentals

Overview

This lecture covers the fundamentals of nursing documentation, focusing on its importance, legal aspects, correct practices, formats, and confidentiality requirements in various healthcare settings.

Purposes and Principles of Documentation

• Documentation is critical for communication among all healthcare team members.
• It serves as a permanent, concise, and accurate record of patient care, past and present.
• Documentation reflects the nursing process and includes assessment, intervention, and evaluation.
• Accountability is tracked through documentation, supporting auditing and monitoring for quality and legal reasons.

Documentation Best Practices and Guidelines

• Always document the intervention, exact time, your signature, and title (e.g., SPN for student practical nurse).
• Entries must be factual, objective, and concise without opinions or judgments.
• Chart care after it is provided, not before, and avoid documenting at shift’s end.
• Use approved abbreviations, correct grammar, and punctuation; no jargon or shorthand not widely accepted.
• Never leave blank spaces or use correction fluid; errors should be corrected per facility policy.

Legal and Ethical Considerations

• Documentation is a legal record that can be used in court; inadequate documentation can increase liability.
• The facility owns the patient record; patients may request (and pay for) copies following protocol.
• Never chart for someone else; chart only what you observe or do.
• Use direct quotes for patient statements when needed; summarize without quotes if paraphrasing.

Types and Formats of Documentation

• Narrative charting: Sequential, organized by system or symptom.
• POMR (Problem-Oriented Medical Record) and SOAP/SOAPIER formats: Structured by problem, subjective/objective data, assessment, plan, interventions, evaluation, and revision.
• Charting by exception: Document only deviations from the norm after an initial full assessment.
• Flow sheets: Used for routine data like vital signs and intake/output.

Electronic and Written Records

• Most facilities use Electronic Health Records (EHR) for efficiency and accuracy.
• Document at the point of care when possible; correct time if charting after the fact.
• EHRs may auto-document data from medical devices and have auto sign-in features.

Special Forms and Reports

• Incident reports are for unusual events and are not part of the legal patient chart.
• Consent forms are signed and witnessed by the nurse; provider must explain the procedure.
• Discharge summaries include care instructions and must be discussed with the patient/family.
• Cardex is an at-a-glance summary (less commonly used now).

Long-Term Care Documentation

• Residents (patients) in long-term care require documentation per state and Medicare/Medicaid standards (MDS — Minimum Data Set).
• Focus on multidisciplinary documentation of therapies and skilled care.

Communication and Reporting

• Change-of-shift, transfer, and critical information reports must be factual, objective, and timely.
• Use ISBAR (Identification, Situation, Background, Assessment, Recommendation) for standardized communication.
• Telephone or verbal orders must be read back and documented.

Confidentiality and HIPAA

• Follow HIPAA: Share information only with those on a need-to-know basis.
• Protect passwords, log off computers, and shred printed patient information.
• Never discuss patient information in public places or with unauthorized individuals.

Key Terms & Definitions

• Charting/Documentation — The process of recording patient care in the health record.
• EHR (Electronic Health Record) — Digital version of a patient’s paper chart.
• ISBAR — Standardized communication tool: Identification, Situation, Background, Assessment, Recommendation.
• SOAP/SOAPIER — Documentation format: Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision.
• Incident Report — Internal document used for reporting unusual events, not part of the legal chart.
• MDS (Minimum Data Set) — Federally mandated assessment for long-term care residents.
• Cardex — A quick-reference summary for patient info (not part of permanent record).
• Consent Form — Legal document for patient agreement to procedures.
• AMA (Against Medical Advice) — Form for patients who leave care against provider’s recommendations.

Action Items / Next Steps

• Review documentation rules (Box 32, p.44 and Table 32, p.45).
• Read examples of incident reports (Table 33, p.54).
• Practice documentation using narrative, flow sheet, and SOAP formats.
• Ensure familiarity with facility policies on documentation and error correction.