Documentation & Reporting Flashcards
What is the purpose of documentation?
1) To communicate
- so everyone involved in the care of the patient knows what is going on
2) To be accountable
- to keep track of WHO is providing care, and WHAT has been done
3) To maintain legal records
- in case any event becomes legal matter
4) To support research
- sometimes documentation can be part of a research study
5) To uphold standards
- it may help support improvements in certain processes around the unit
Importance of Documentation
- Communication about client‘s health status and needs to all members of the health care team
- Communication of a client centred plan of care to other nurses
- Communication of changes in a client’s condition or situation
- Communication of a client’s educational/information needs
Documentation Standards and Legal Implications
- Communication: Nurses ensure that documentation presents an accurate, clear and comprehensive picture of the client’s needs, the nurse’s interventions and the client’s outcomes.
- Accountability:Nurses are accountable for ensuring their documentation of client care is accurate, timely and complete.
- Security:Nurses safeguard client health information by maintaining confidentiality and acting in accordance with information retention and destruction policies and procedures that are consistent with the standard(s) and legislation.
- Charting is a LEGAL document that can be used in court
- Documentation should include ALL the client care that is provided by the nurse in chronological order from admission until discharge
Progress Notes
- are long-form notes that explain and describe events. - These notes go on the chart for everyone to read so that the whole team is updated on the client’s condition.
- This type of documentation (charting) requires your signature & designation).
- use a line at the end so others can not add to what you wrote
- if you forget to write something, add an addendum later
- if you ask another nurse to administer medication, but you did not administer it yourself, do not write it down
Well-written notes are:
- written in black or blue pen (never pencil or other pen colours)
- focused
- clear
- concise
- professional
- informative
Poorly written notes are:
- do not isolate the issue
- are disorganized, and hard to read
- are wayy too long
- are missing information
- do not tell you anything helpful
Types of Documentation
The most common formats are
1. DAR (data, action, recommendation)
- SOAP (subjective, objective, assessment, plan)
How to write the date & time on a progress note.
Date
- INTERNATIONAL STANDARD yyyy/mm/dd
Always check with your employing institution
Time
- use the 24 hour clock
- no am/pm
- no : (colon) between the numbers
- include the ‘0’ with morning times (0815)
- write 4 numbers only, at all times.
Things NOT to do for progress notes
- never scribble
- add forgotten things in the margin
- never squeeze words in with a ^ above the space
- Don’t leave spaces to write in later, for others to add data, or because you like the way it looks.
Professional & legal guidelines/responsibilities regarding documentation (applied to our BScN, year 1 program)
- DO NOT leave blank spaces in the note
- Write legibly & in ink
- Chart only for yourself
- Avoid using generalized phrases
- Begin each entry with date, time
○INTERNATIONAL STANDARDyyyy/mm/dd - End each entry with first initial,fulllast name & designation (WFN-1)
- The # changes as you advance through the program
- Be considerate of language used
- The nurse documents as soon as possibleafter the client interaction.
Best Practices for Correcting an Error
- DO NOT erase or use white out
- If you make a mistake when hand-writing or typing a note, you need to fix it in a way that allows the first thing you wrote to be legible or retrievable.
Why?
- All documentation can be brought into court.
- Everything, even mistakes, should be accessible.
- Draw one single line through written mistakes, initial, and then keep writing.
- Follow your agency’s rules about fixing mistakes using their electronic documentation platform.
Principles of Documentation
You documentation should BE:
- Factual
- Accurate
- Concise
- Complete
- Organized
- Specific
Your documentation
should INCLUDE:
- Proper grammar
- Spelling
- Punctuation
- Professional language/ terminology
- Factual
- Avoids words such as “seems” or “appears” (it suggests an opinion, not a fact)
- Avoid vague words such as “good” or “normal”,(what is good to 1 practitioner may not be good to another)
- Avoid giving an opinion, such as “client progressing well” (this is an interpretation and “well” is vague)
- Objective data are the things you see and do. There is no interpretation required. Data are FACTS, and they inform your client assessment.
- 1 common mistake made is when documenting objective data is including language that implies subjective interpretation.
- Recording only the facts means careful and clear wording is used to communicate your findings.
- Certain words (ie. seems, appears, normal, anxious) are RED FLAGS in documentation and should not be used.
- Accurate
- Be precise: describe in detail what was assessed, observed, measured
- Ensure proper terminology is used
- Ensure proper grammar and spelling are used to reflect nursing competency. (If something is poorly written, people make assumptions about the writer’s level of knowledge and skill)
- Document your own assessments, not the impressions or assessments of others. Your signature indicates that you assume responsibility for the information documented on the chart
- Do not include information given to you from someone on another shift, as the client’s condition may change, or the information may not be accurate at the time of your documentation
- Ensure documentation is done within a reasonable timeframe
- Concise
- Focuson one note per issue
- Include only relevant information.
- Ask yourself “What is important to know?” and do not include extraneous details
- Use only approved abbreviations to avoid confusion and misinterpretation
