Documentation

Patient Medical Record

Purposes
Legal Document
Financial
reimbursement
Communication
and Care Planning

Education

Quality Assurance
Research

Components of the Medical

Record

Nursing admission assessment

H & P by the primary and consulting MDs
MD orders
Plan of care
Flow sheetsvital signs, I & Os, routine assessments
Focused assessments
Medication administration record/eMAR
Laboratory and diagnostic record
Progress notes
Consultations
Discharge and transfer summaries

Principles of Documentation
Confidential

Timely
Accurate and
complete

Concise
organized

Clinical Significance
Clear documentation that reflects
time sequencing is especially
important for patients with unstable
conditions. If litigation occurs,
lawyers use documentation to
reconstruct the sequence of events,
the time of interventions, and the
time that providers were notified. In
a code or emergency, the team
should designate a single member to

Because assessment requires much

critical thinking and clinical judgment
and is a professional responsibility,
nurses cannot delegate it to an
unlicensed personnel.

Documentation Formats
Narrative
SOAP (IE)
PIE
Focus
Charting by exception

Narrative
Format: information written in
phases, usually time sequenced
Advantages: easy to learn, easy to
adjust length, can explain in detail
Disadvantages: time consuming,
difficult to retrieve information, may
include irrelevant information,
possibly unfocused and disorganized

Narrative
11/10/10, 1500; Pt c/o of 8/10 in rt
hand; states he is using his PCA, but
it doesnt help. Notified MD of pain
level at 1430. Pain is throbbing from
fingers to elbow. Pain increases with
movement. Fingers to left hand pink
and warm with brisk cap. refill. Left
radial pulse +2. Rt hand cool to
touch with delayed cap. refill of >6
seconds. Waiting for MD to arrive

SOAP (IE)

Ssubjective data
Oobjective data
Aanalysis
Pplan
Iintervention
E--evaluation

SOAP (IE)
Advantages: all charting focuses
on identified or new problems,
interdisciplinary, easy to track
progress or identify problems, similar
to steps in nursing process
Disadvantages: lengthy and time
consuming, repeats assessment data
on flow sheets

SOAP (IE)
Sstates pain 8/10 from elbow to fingertips
OCap refill > 6 secs, cool to touch
Areduced tissue perfusion to rt hand r/t
injury and inadequate pain control
Pcontact Dr. Smith to eval patient.
Waiting for MD arrival
IMorphine 4 mg IVP
Eevaluate pain med effectiveness in 30
minutes

PIE
P: problem
I: intervention
E: evaluation

PIE
Advantages: incorporates POC,
includes outcomes which increase
quality assurance, less redundancy,
easily adapted to computer charting
Disadvantages: may need to read
progress note to determine POC if
not on separate document, not
multidisciplinary

PIE
Pinadequate tissue perfusion
IDr. Smith contacted at 1430 to
report pain and assessment findings.
MD evaluated patient. Pain orders
received
EDr. Smith reports no change in
circulation since admission.
Continue hourly neurovascular
checks, evaluate pain q30mins.
J. Steele, RN

Charting by Exception
Format: standards metsign or check
off, standards not metwrite narrative
or SOAP note
Advantages: efficient, no duplicate
charting b/c assessments are on flow
sheets, clearly outlines abnormal findings.
Disadvantages: expensive to develop
and educate staff, not prevention focused,
may pose legal problems b/c details are
often missing

Handoff
Occurs when care for a patient is
transferred from one health provider
to another.
Receiving staff must have up-to-date
assessment data
Common situations:
Shift change
Meal breaks
Transfer to a different unit or level of
care

Strategies for Effective

handoff
Use a standardize formatSBAR
Communicate face to face with
current and historical data
Ensure limited interruptions
Use read-back policies
Use written documentation to
supplement handoff

SBAR
Ssituation, state concisely why
you are communicating
Bbackground, describe
circumstances that lead up to the
situation
Aassessment, give
objective/subjective data pertinent to
situation
Rrecommendation, make
suggestions for what needs to be