CHARTING BASICS

What Is Documentation?
Documentation means to give written information that is proof or support of
something that has been done or observed. Simply put, a medical record is the
record of all care that is provided. If it is not recorded, it did not happen. If it is
recorded incorrectly, it happened incorrectly. A nurses documentation provides a
clear picture of the status of the patient, the actions of the nurse, and the patient
outcomes.

Reasons for documentation:
To facilitate communication
Through documentation, nurses communicate to other nurses and care
providers their assessments about the status of patients, nursing
interventions that are carried out and the results of these interventions.
Documentation of this information increases the likelihood that the
patient will receive consistent and informed care or service.
Thorough, accurate documentation decreases the potential for
miscommunication and errors.

To promote good nursing care
Documentation encourages nurses to assess patient progress and
determine which interventions are effective and which are ineffective,
and identify and document changes to the plan of care as needed.

To meet professional and legal standards
Documentation is a valuable method for demonstrating that, within
the nurse-patient relationship, the nurse has applied nursing
knowledge, skills and judgment according to professional standards.
The nurses documentation may be used as evidence in legal
proceedings such as lawsuits, coroners inquests, and disciplinary
hearings through professional regulatory bodies. In a court of law, the
patients health record serves as the legal record of the care or service
provided. Nursing care and the documentation of that care will be
measured according to the standard of a reasonable and prudent nurse
with similar education and experience in a similar situation.



To assure reimbursement of the cost of care
In health care, sometimes private insurance and Medicare will deny
payment if documentation is not satisfactory or is not done at all.
Payment can be denied if documentation is missing or incomplete.

Good documentation has five important characteristics. It should be: 1) factual; 2)
accurate; 3) complete; 4) current (timely); and 5) organized. If the accuracy of a
nurses charting is questioned in a court of law, questions might be raised about the
credibility of both the documentation and the nurse (RN, 2003). The timeliness of
documentation will be dependent upon the patient. When patient acuity,
complexity and variability are high, documentation will be more frequent than
when patients are less acute, less complex and/or less variable. Patients who are
very ill, considered high risk, or have complex health problems generally require
more comprehensive, in-depth and frequent documentation.

Types of charting
Flow sheets and checklists are frequently used to document routine and ongoing
assessments and observations such as personal care, vital signs, intake and output,
etc. Information recorded on flow sheets or checklists does not need to be repeated
in the progress notes.

Focus charting progress notes are used to document patient progress in meeting
established goals. Common formats include SOAP, SOAPIER, PIE, and DAR.

What information is included in the progress notes?
Progress notes (nurses notes) are used to communicate nursing assessments,
interventions carried out, and the impact of these interventions on patient
outcomes. In addition, progress notes are intended to include:
patient assessments prior to and following administration of PRN
medications;
information reported to a physician or other health care provider and,
when appropriate, that providers response;
all patient teaching;
all discharge planning, including instructions given to the patient
and/or family and planned community follow-up;
all pertinent data collected in the course of providing care, including
data collected through technology such as monitoring devices (e.g.,
strips produced during cardiac or fetal monitoring); and
action taken by the nurse on behalf of the patient (including calls to
physician and discussions with other health care team members).

Examples of DAR notes
DAR is a form of focus charting. A note is written to provide
documentation related to a specific focus. The focus might be a nursing
diagnosis, patient problem, sign or symptom, change in patients condition,
or any significant event. The progress note is written in DAR format which
stands for Data-Action-Response.
Data: Subjective and/or objective information that supports the stated
focus or describes the patient status at the time of a significant event
or intervention.
Action: Completed or planned nursing interventions based on the
nurses assessment of the patients status and any changes to the care
plan deemed appropriate.
Response: Description of the patients response to nursing or medical
care and progress in achieving outcomes/goals.
DAR notes do not need to always have all three components. Some notes
will just contain one or two of the three parts.

Example 1 Focus: Nausea related to anesthetic
D: States she's nauseated. Vomited 100ml clear fluid at 2255
A: Given Compazine 1mg IV at 2300.
R: Reports no further nausea at 2335. No further vomiting.

Example 2 Focus: Acute pain related to surgical incision
D: Reports pain as 7/10, grimaces and groans with movement BP 154/88.
Had received PO analgesic at 2200.
A: Given morphine 1mg IV at 2335. Repositioned on left side.
R: Reports pain as 1/10 at 2355. BP 138/82.

Example 3 Focus: Risk for infection related to incision sites
D: Incision site in front of left ear extending down and around the ear and
into neck14 cm in length--without dressing. Jackson-Pratt drain in left
neck below ear secured in place with suture.
A: Assess site and emptied drain. Taught patient S&S of infection.
R: No swelling or bleeding; bruising below left ear noted. JP drained 20mL
bloody drainage. States understanding of teaching.

Example 4 Focus: Delayed surgical recovery
D: C/O dizziness after trying to get OOB to use the bathroom.
A: Assisted patient back in bed and with use of bedpan by CNA. Taught
how to dangle legs and get OOB slowly. Taught coughing and deep
breathing exercises, turning in bed, and use of anti-embolism stockings.
R: Voided 200mL in bedpan. Did cough and deep breathing appropriately.
Lungs clear bilaterally. Anti-embolism stockings on.

Example 5 Focus: Medications
D: Wife stated patient takes Synthroid 0.125 mg daily, has for 12 years.
A: Physician notified, order received, Synthroid given.

Note:
Complete sentences arent used.
It is assumed that a note in a particular patients chart is written about that
patient.
It is assumed that the nurse writing the note performed the actions unless
otherwise indicated.
The reasons for the action usually arent included nor are the nurses
thoughts about the situation.



SUMMARY
What to do:
o Check to be sure you have the correct chart before you begin writing
o Make sure your documentation reflects the nursing process
o Chart completely but be concise (and accurate!)
o Chart time for each entry
o Document unexpected findings/occurrences
o Chart precautions or preventative measures
o For procedures, include the following: what was done, when it was done,
who did it, how it was done, how the patient tolerated it, adverse reactions, if
any.
o Record each phone call to or from a physician, including exact time,
message, and response.
o Chart as soon as possible after providing care.
o Chart a patients refusal of treatment or medications.
o If you remember something important after you have completed your
documentation, write late entry and make the note.

In hand-written forms:
o Write LEGIBLY using a permanent black ink pen (other colors do not
photocopy well)
o If you make a mistake, draw a line through the error, and indicate it as an
error, and then initial it.

What not to do:
o Dont chart a symptom such as c/o pain without also writing what you did
about it.
o Dont alter a chart.this is a criminal offense.
o Dont add information at a later date without indicating that you did so.
o Dont date the entry so that it appears to have been written at an earlier time.
o Dont use shorthand or abbreviations that are not standard.
o Dont write vague descriptions such as large amount of drainage
o Dont make excuses, such as meds not given because not available.
o Dont chart what someone else says unless you use quotations and state who
said it.
o Dont chart an opinion.
o Dont use words that suggest a negative attitude, such as weird or nasty.
o Dont chart ahead of time. If something happens it will look bad to go back
and make that correction.
o Misspelled words and bad grammar are as bad as illegible handwriting.
o Dont record staffing problems.
o Dont document that an incident report was completed.
o Dont leave any blank spaces.
o Dont save a space for a colleague who forgot to chart.
o Dont chart care that was not given. This is fraud and cause for loss of
license.

Electronic health records:
o Never reveal or allow anyone access to your personal identification number
or passwords (these are, in fact, electronic signatures).
o Log off when not using a system or when leaving a terminal.
o Shred any print information containing patient information.
o Retrieve printed information promptly.

SBAR Situation, Background, Assessment, Recommendation is a standardized
way of communicating.

Improving the communication between caregivers can prevent negative patient
outcomes and strengthen a teamwork approach to care. The SBAR technique
provides common expectations such as what will be communicated, how it's
structured, and what are the required elements. It allows communication to be
focused on the problem and not the people. This is very important when staff
members are communicating hand-off information at the change of shifts.

The SBAR technique also provides a way to hand-off relevant information in
the presence of the patient, allowing active participation of the patient in his or
her care. The patient is central to all information surrounding care activities.
Patients can ask questions or add information to the discussion. Through this
process, the patient sees the staff working as a team and is assured that all
involved know and agree on the plan of care. Evidence suggests that better-
informed patients are less anxious and more likely to follow medical advice.

Situation. The "S" component should take about 8 to 12 seconds. The nurse
states what's happening now. If giving a shift report to the next caregiver, the
nurse states the patient's name, why the patient is on the unit, and introduces the
nurse coming on duty to the patient. For example: "Ms. J, this is Tina Jones, the
registered nurse who will be caring for you today. Tina, Ms. J is here to have
rehab after her right knee replacement." To be effective, you must be concise,
clear, and to the point when giving the report, leaving irrelevant information out
of the conversation.

Background. During the "B" component, the nurse gives the next caregiver
brief background information specific to the patient's relevant history. This
section sets the context for what's being discussed, which may include the
patient's diagnosis, history of procedures done, and family situation. For
example: "Ms. J had a right knee replacement on June 3rd by Dr. Smith. She
has a history of hypertension, diabetes, and arthritis. She lives with her husband
who's retired and able to care for her at home when discharged."

Assessment. During the "A" component, the nurse reports the current condition
of the patient. For example: "Blood glucose levels have been stable, vital signs
within normal limits, and the incision line is clean and dry with no drainage
noted. The dressing was changed today. Ms. J is able to ambulate to the
restroom with a contact guard of one and the use of a walker. Her pain has been
reported as a 7 on a 0-to-10 scale and she was given two hydrocodone pills at 9
a.m. The hydrocodone appears to be helping her, especially when given before
therapy."

Recommendation. During the "R" component, the nurse states what he or she
thinks would be the desired response to the patient's care of the day. She may
suggest that discharge planning be initiated by discussing needs with the
patient, contacting the physician with discharge plans, and conveying to the rest
of the care team what needs to be done before discharge. You don't need to read
the entire patient profile or orders. For example: "Ms. J is scheduled for
discharge this Friday and will need to speak to the discharge planner today."

Remember, not everything about the patient needs to be conveyed, just what's
pertinent to the situation at that time. Also remember that effective
communication takes two: Ask if there are any questions and remind team
members and the patient that you'll be available should further clarification be
needed.

http://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2011/09000/Looking_to_improve_your_bedside_report__Try_SBAR.14.aspx


RN to Physician SBAR Examples

Scenario 1: An RN on the Medical Floor has an order for a patient to receive an
exam that requires IV contrast. The patients creatinine level is 2.9. The
ordering physician needs to be called to clarify this order.

Situation: Dr. Smith, this is Darlene on Med/Surg at OMH. I have an order
for a PE study for Mr. Marino. His creatinine is elevated and I wanted to
clarify the order with you.

Background: I see that Mr. Marino came into the ED with right-sided chest
pain and difficulty breathing. The CT for rule-out PE was ordered.

Assessment: Mr. Marinos creatinine level is 2.9, far above the allowable
level for a rule-out PE study.

Recommendation: I think that the order should be changed from a CT for
rule-out PE to an order for a VQ scan.

Scenario 2: A nurse wants to report a change in patient condition to the
physician.

Situation: Dr. Thomas, this is Lisa in ICU at OMH. I am caring for Mr.
Jones, in room 5. Mr. Jones has had a change in his heart rhythm.

Background: Mr. Jones had his hip surgery two days ago and has been
going in and out of controlled A-fib since his surgery, with rates in the high
90s. Mr. Jones has a history of A-fib and was on Coumadin 5 mg/day and
Digoxin 0.25 mg/day prior to his hip replacement. He has not had any
Digoxin or Coumadin since his surgery.

Assessment: This morning, Mr. Jones has gone into an uncontrolled A-fib,
with a rate in the 120-130 range. He is currently asymptomatic and his vital
signs are stable, with a blood pressure of 120/80. He is resting comfortably
in his room.

Recommendation: I am thinking that a 12-lead should be ordered for Mr.
Jones. Would you like his Digoxin and/or his Coumadin to resume? Are
there any other tests you would like to order? I will call you if Mr. Jones
converts or becomes symptomatic. Would you like me to call you with any
other information?


Scenario 3: A patient is being admitted to OB in early labor. The RN needs to
give an update to the on-call Obstetrician.

Situation: Hello, this is Jenny from OB at OMH calling to let you know
that Mrs. Winslow has been admitted in early labor.

Background: Mrs. Winslow presented to the ED around 1600 this evening.
She is a 40-year-old Gravida1para2. She started in labor at 0900 today. She
is RH+, GBS positive, and Rubella immune. Her Hepatitis status is
unknown. Her membranes are intact. Mrs. Winslow has an allergy to
Penicillin, reaction unknown, but became allergic to Penicillin as a child.

Assessment: Mrs. Winslow has been on the monitor for 30 minutes, is
contracting every 5 minutes. She is dilated to 3 cm, 70% effaced, and 1
station. Baseline FHT is 130, with average variability; there are
accelerations of 15-beats/minute and no decelerations. Her vital signs are
stable at 98.9 F, BP 130/68, Pulse 100, and RR 24. Mrs. Winslow does not
want an epidural.

Recommendation: May I enter your L&D order set? Since Jane is HBSAG
positive, what treatment would you like? Would you like any other lab tests?
How would you like me to contact you today?

Scenario 4: A patient who is post-surgical ankle repair is having unsuccessful
pain control. The RN needs to get an order for improved pain coverage.

Situation: Hello, this is Ron from Med/Surg at OMH. Im caring for Mr.
Tree in room 3. Im calling regarding his pain control.

Background: Mr. Tree is a 22-year old who had surgical repair of a
fractured ankle 2 days ago. He has had very minimal pain control since his
surgery. He has an order for
Tylenol 650 mg q 4 hours for minimal to moderate pain and Morphine IV, 1-
4 mg q 2 hours for severe pain. He does not have any allergies to
medications. This is his first time having any type of surgery or significant
injury.

Assessment: Mr. Tree ranks his pain as a 9/10, with a quality of being sharp
and radiating to his mid-calf area. He is reluctant to ambulate out of bed,
even refusing to get into a chair at the bedside. His pedal pulses are equal,
the surgical site is WNL, and all of his vital signs are stable.

Recommendation: I think that Mr. Tree would benefit from some longer-
lasting pain medications. What would you prefer to order? Are there any
exams or labs you would like to order? What should I call you for in the
future regarding his pain control?

http://www.prohealthcare.org/pdf/SBAR%20template%20RN%20to%20Doc.pdf