2.5 Documentation

Using Technology to Access Information

Most client information in acute care, long-term care, and other clinical settings is now electronic and uses intranet technology for secure access by providers, nurses, and other health care team members to maintain client confidentiality. Intranet refers to a private computer network within an institution. An electronic health record (EHR) is a real-time, client-centered record that makes information available instantly and securely to authorized users.^[1] Computers used to access an EHR can be found in client rooms, on wheeled carts, in workstations, or even on handheld devices. See Figure 2.11^[2] for an image of a nurse documenting in an EHR.

The EHR for each client contains a great deal of information. The most frequent pieces of information that nurses access include the following:

• History and Physical (H&P): A history and physical (H&P) is a specific type of documentation created by the health care provider when the client is admitted to the facility. An H&P includes important information about the client’s current status, medical history, and the treatment plan in a concise format that is helpful for the nurse to review. Information typically includes the reason for admission, health history, surgical history, allergies, current medications, physical examination findings, medical diagnoses, and the treatment plan.
• Provider orders: This section includes the prescriptions, or medical orders, that the nurse must legally implement or appropriately communicate according to agency policy if not implemented.
• Medication Administration Records (MARs): Medications are charted through electronic medication administration records (MARs). These records interface the medication orders from providers with pharmacists and are also the location where nurses document medications administered.
• Treatment Administration Records (TARs): In many facilities, treatments such as wound care are documented on a treatment administration record.
• Laboratory results: This section includes results from blood work and other tests performed in the lab.
• Diagnostic test results: This section includes results from diagnostic tests ordered by the provider such as X-rays, ultrasounds, etc.
• Progress notes: This section contains notes created by nurses and other health care providers regarding clientcare. It is helpful for the nurse to review daily progress notes by all team members to ensure continuity of care.

Legal Documentation

Nurses and health care team members are legally required to document care provided to clients. Any type of documentation in the EHR is considered a legal document. In a court of law, it is generally viewed that, “If it wasn’t documented, it wasn’t done.”  Other documentation guidelines include the following:

• Documentation should be objective, factual, and professional. Only document what you personally assessed, observed, or performed.
• Proper medical terminology, grammar, and spelling should be used.
• All types of documentation must include the date, time, and signature of the person documenting.
• Abbreviations should be avoided in legal documentation.
• Documentation must be completed in an accurate and timely manner after the task is performed. Do not document in advance of completing a task.
• Assessments, interventions, medications, or treatments that were not completed should never be charted as completed. This is considered falsification and can present serious legal ramifications for the nurse and the health care facility.
• When using paper documentation, avoid leaving blank lines to prevent others from adding to your documentation. In the event of a charting error, draw a single line through the error and write, “mistaken entry” above the line with your initials. Errors should never be erased, scribbled out, or covered with white-out.
• If electronic documentation is charted in error, it should be corrected with the details of the error and the correction noted in the background should the need arise to review the documentation.

Documentation is used for many purposes. It is used to ensure continuity of care across health care team members and across shifts; monitor standards of care for quality assurance activities; and provide information for reimbursement purposes by insurance companies, Medicare, and Medicaid. Documentation may also be used for research purposes or, in some instances, for legal concerns in a court of law.

Documentation by nurses includes recording client assessments, writing progress notes, and creating or addressing information included in nursing care plans. Nursing care plans are further discussed in the “Planning” section of the “Nursing Process” chapter.

Common Types of Documentation

Common formats used to document client care include charting by exception, focused DAR notes, narrative notes, SOAPIE progress notes, client discharge summaries, and Minimum Data Set (MDS) charting.

Charting by Exception

Charting by exception (CBE) documentation was designed to decrease the amount of time required to document care. CBE contains a list of normal findings. After performing an assessment, nurses confirm normal findings on the list found on assessment and write only brief progress notes for abnormal findings or to document communication with other team members.

Focused DAR Notes

Focused DAR notes are a type of progress note that are commonly used in combination with charting by exception documentation. DAR stands for Data, Action, and Response. Focused DAR notes are brief. Each note is focused on one client problem for efficiency in documenting and reading.

• Data: This section contains information collected during the client assessment, including vital signs and physical examination findings found during the “Assessment” phase of the nursing process. The Assessment phase is further discussed in the “Nursing Process” chapter. Think of the “Data” section as describing the main problem.
• Action: This section contains the nursing actions that are planned and implemented for the client’s focused problem. This section correlates to the “Planning” and “Implementation” phases of the nursing process and are further discussed in the “Nursing Process” chapter. Think of the “Action” section as describing what was done about the problem.
• Response: This section contains information about the client’s response to the nursing actions and evaluates if the planned care was effective. This section correlates to the “Evaluation” phase of the nursing process that is further discussed in the “Nursing Process” chapter. Think of the “Response” section as describing the result of what happened after performing the actions.

Narrative Notes

Narrative notes, also called summary notes, are a type of progress note that chronicles assessment findings and nursing activities for the client that occurred throughout the entire shift or visit. View sample narrative note documentation for body system assessments in the Open RN Nursing Skills, 2e textbook.

SOAPIE Notes

SOAPIE is a mnemonic for a type of progress note that is organized by six categories: Subjective, Objective, Assessment, Plan, Interventions, and Evaluation. SOAPIE progress notes are written by nurses, as well as other members of the health care team.

• Subjective: This section includes what the client said, such as,  “I have a headache.” It can also contain information related to pertinent medical history and why the client is in need of care.
• Objective: This section contains the observable and measurable data collected during a client assessment, such as the vital signs, physical examination findings, and lab/diagnostic test results.
• Assessment: This section contains the interpretation of what was noted in the Subjective and Objective sections, such as a nursing diagnosis in a nursing progress note or the medical diagnosis in a progress note written by a health care provider.
• Plan: This section outlines the plan of care based on the Assessment section, including goals and planned interventions.
• Interventions: This section describes the actions implemented.
• Evaluation: This section describes the client response to interventions and if the planned outcomes were met.

Discharge Summary

When a client is discharged from an agency, a discharge summary is documented in the client record, along with clear verbal and written client education and instructions provided to the client. Discharge summary information is frequently provided in a checklist format to ensure accuracy and includes the following:

• Time of departure and method of transportation out of the hospital (e.g., wheelchair)
• Name and relationship of person accompanying the client at discharge
• Condition of the client at discharge
• Client education completed and associated educational materials or other information provided to the client
• Discharge instructions on medications, treatments, diet, and activity
• Follow-up appointments or referrals given

See Figure 2.12^[5] for an image of a nurse providing discharge instructions to a client. Discharge teaching typically starts at admission and continues throughout the client’s stay because this allows for reinforcement of teaching topics.

Minimum Data Set (MDS) Charting

In long-term care settings, additional documentation is used to provide information for reimbursement by private insurance, Medicare, and Medicaid. The Resident Assessment Instrument Minimum Data Set (MDS) is a federally mandated assessment tool created by registered nurses in skilled nursing facilities to track a client’s goal achievement, as well as to coordinate the efforts of the health care team to optimize the resident’s quality of care and quality of life.^[6] This tool also guides nursing care plan development.

Incident Reports

Incident reports, also called variance reports, are a specific type of documentation that is completed when there is an unexpected occurrence, such as a medication error, client injury, client fall, or a near miss, where an error did not actually occur, but was prevented from occurring. Refer to agency policies for specific events requiring incident reports.

Incident reports are completed by the staff member involved in the occurrence. Documentation includes the date and time of the event, client involved (if applicable), what occurred, what was done in response to the event, what else was happening at the time the incident occurred, as well as other facility specific required data. Abbreviations, assumptions, or interpretations should be avoided.

Incident reports are intended to be used as a safety tool to identify system issues and process problems that could benefit from quality and safety improvements. Incident reports should be used as component of a safety culture, not punitively. If used punitively, staff become reluctant to report errors or suggest process improvements for fear of “getting in trouble.”

Incident reports are not a part of the medical record and should not be mentioned in the medical record. However, the specific event should be documented in the medical record, along with health care provider notification and interventions provided.^[7]