1 Documenting and Reporting I

Documenting and Reporting

REPORT- oral, written, or computer-based communication intended to convey information to others. For
instance, nurses always report on clients at the end of a hospital work shift.

RECORD, CHART OR CLIENT RECORD - a formal, legal document that provides evidence of a
client’s care and can be written or computer based. Although health care organizations use different systems and
forms for documentation, all client records have similar information. The process of making an entry on a client
record is called recording, charting, or documenting.

“. . . the nurse has a duty to maintain confidentiality of all patient information”

PURPOSES OF CLIENT RECORDS

Communication
The record serves as the vehicle by which different health professionals who interact with a client
communicate with each other. This prevents fragmentation, repetition, and delays in client care.
Planning Client Care
Each health professional uses data from the client’s record to plan care for that client. A primary care
provider, for example, may order a specific antibiotic after establishing that the client’s temperature is steadily
rising and that laboratory tests reveal the presence of a certain microorganism. Nurses use baseline and ongoing
data to evaluate the effectiveness of the nursing care plan.
Auditing Health Agencies
An audit is a review of client records for quality assurance purposes. Accrediting agencies such as The
Joint Commission may review client records to determine if a particular health agency is meeting its stated
standards.
Research
The information contained in a record can be a valuable source of data for research. The treatment plans
for a number of clients with the same health problems can yield information helpful in treating other clients.
Education
Students in health disciplines often use client records as educational tools. A record can frequently
provide a comprehensive view of the client, the illness, effective treatment strategies, and factors that affect the
outcome of the illness.
Reimbursement
Documentation also helps a facility receive reimbursement from the federal government. For a facility to
obtain payment through Medicare, the client’s clinical record must contain the correct diagnosis related group
(DRG) codes and reveal that the appropriate care has been given.
Codable diagnoses, such as DRGs, are supported by accurate, thorough recording by nurses. This not only
facilitates reimbursement from the federal government, but also facilitates reimbursement from insurance
companies and other third-party payers. If additional care, treatment, or length of stay becomes necessary for the
client’s welfare, thorough charting will help justify these needs.
Legal Documentation
The client’s record is a legal document and is usually admissible in court as evidence. In some
jurisdictions, however, the record is considered inadmissible as evidence when the client objects, because
information the client gives to the primary care provider is confidential.
Health Care Analysis
Information from records may assist health care planners to identify agency needs, such as overutilized
and underutilized hospital services.
Records can be used to establish the costs of various services and to identify those services that cost the agency
money and those that generate revenue.
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DOCUMENTATION SYSTEMS

A. Problem-Oriented Medical Record – established by Lawrence Weed

- In the problem-oriented medical record (POMR), or problem-oriented record (POR), the data are arranged
according to the problems the client has rather than the source of the information. Members of the health
care team contribute to the problem list, plan of care, and progress notes.
- Plans for each active or potential problem are drawn up, and progress notes are recorded for each
problem.

Advantages Disadvantages
(a) it encourages collaboration (a) caregivers differ in their ability to use the required
charting format
(b) the problem list in the front of the chart alerts (b) it takes constant vigilance to maintain an up-to-
caregivers to the client’s needs and makes it easier date problem list, and
to track the status of each problem. (c) it is somewhat inefficient because assessments and
interventions that apply to more than one problem
must be repeated.

Four Basic Components

I. DATABASE
- The database consists of all information known about the client when the client first enters the health care
agency. It includes the nursing assessment, the primary care provider’s history, social and family data, and the
results of the physical examination and baseline diagnostic tests. Data are constantly updated as the client’s health
status changes.

II. PROBLEM LIST

- Derived from the database.
- Usually kept at the front of the chart and serves as an index to the numbered entries in the progress notes.
- Problems are listed in the order in which they are identified, and the list is continually updated as new
problems are identified and others resolved.
- All caregivers may contribute to the problem list, which includes the client’s physiological,
psychological, social, cultural, spiritual, developmental, and environmental needs.
- Primary care providers write problems as medical diagnoses, surgical procedures, or symptoms; nurses
write problems as nursing diagnoses.
** As the client’s condition changes or more data are obtained, it may be necessary to “redefine” problems.

III. PLAN OF CARE

- The initial list of orders or plan of care is made with reference to the active problems. Care plans are
generated by the individual who lists the problems. Primary care providers write physician’s orders or
medical care plans; nurses write nursing orders or nursing care plans. The written plan in the record is
listed under each problem in the progress notes and is not isolated as a separate list of orders.

IV. PROGRESS NOTES

- A progress note in the POMR is a chart entry made by all health professionals involved in a client’s care;
they all use the same type of sheet for notes. Progress notes are numbered to correspond to the problems
on the problem list and may be lettered for the type of data.

**In addition, flow sheets and discharge notes are added to the record as needed.
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b. sOAPIE
The system eliminates the traditional care plan and incorporates an ongoing care plan into the progress
notes. Therefore, the nurse does not have to create and update a separate plan. A disadvantage is that the nurse
must review all of the nursing notes before giving care to determine which problems are current and which
interventions were effective.

S—Subjective data consist of information obtained from what the client says. It describes the client’s perceptions
of and experience with the problem. When possible, the nurse quotes the client’s words; otherwise, they are
summarized. Subjective data are included only when it is important and relevant to the problem.
“I feel sick”
“ Marigatan ak nga ag anges”
Pain rated as 7 in a scale of 1 to 10, 10 being severe
“Masakit dito sa may bandang puso ko”
O—Objective data consist of information that is measured or observed by use of the senses .
Deviation in V/S Peripheral cyanosis
o 160/90 mmHg Warm to touch
o 25 CPM Flushed skin
o 120 BPM Grimace
Pale conjunctiva Laboratory results
Use of accessory muscles when breathing S/P
Circumoral cyanosis
A—Assessment is the interpretation or conclusions drawn about the subjective and objective data. During the
initial assessment, the problem list is created from the database, so the “A” entry should be a statement of the
problem. In all subsequent SOAP notes for that problem, the “A” should describe the client’s condition and level
of progress rather than merely restating the diagnosis or problem.
“ Acute severe pain related to traumatized tissue secondary to recent surgical procedure”
“Ineffective airway clearance related to increased mucus production on the respiratory tract secondary to
infection as evidenced by crackles”
P—The plan is the plan of care designed to resolve the stated problem.
The initial plan is written by the person who enters the problem into the record. All subsequent plans, including
revisions, are entered into the progress notes.
After 1 hour of nursing interventions, client would demonstrate proper coughing and breathing exercises
After 1 hour of nursing interventions, client would rate pain as 3 or minimal
I—Interventions refer to the specific interventions that have actually been performed by the caregiver.
Established rapport
Vital signs taken and recorded
Assessed location, severity, contributing factors to pain
Assessed surgical incision for any signs of infection
Repositioned to semi fowlers
O2 inhalation started at 2-3 LPM per nasal cannula
Administered pain medication as ordered
Instructed to do DBE
Encouraged to talk with S.O to distract attention from pain
Advised to stay in semi fowlers and to report increase in pain severity
E—Evaluation includes client responses to nursing interventions and medical treatments. This is primarily
reassessment data.
Time > result
7:40 > temperature decreased to 37.4 C

Newer versions of this format eliminate the subjective and objective data and start with assessment, which
combines the subjective and objective data. The acronym then becomes AP, APIE, or APIER.
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***Receiving statement
Received awake on bed in semi-fowler’s position, with an ongoing IVF of D5NSS i L x 8° at 650 mL
level, infusing well at L arm.
Received awake sitting on bed, with an on going IVF of PNSS i L x KVO at 900 mL level, infusing on R
arm, with SD of PRBC i unit x 4°, Blood type O, Rh (+), serial number 998237485, tubing number
23278495 infusing well at 200 mL level.
Received awake on bed in high fowler’s, with an ongoing IVF of D5LRS i L x 8° at 300 mL level
infusing well at L arm, with an ongoing IVF of PNSS i L x KVO at 900 mL level infusing well on R arm
with SD of PRBC i unit x 4°, Blood type O, Rh (+), serial number 998237485, tubing number 23278495,
with a patent IFC connected to urine bag draining yellowish urine.

C. Focus Charting
Focus charting is intended to make the client and client concerns and strengths the focus of care. Three
columns for recording are usually used: date and time, focus, and progress notes.

Focus - may be a condition, a nursing diagnosis, a behavior, a sign or symptom, an acute change in the
client’s condition, or a client strength.
Data- category reflects the assessment phase of the nursing process and consists of observations of client
status and behaviors, including data from flow sheets (e.g., vital signs, pupil reactivity). The nurse records both
subjective and objective data in this section.
Action- reflects planning and implementation and includes immediate and future nursing actions. It may also
include any changes to the plan of care.
Response -reflects the evaluation phase of the nursing process and describes the client’s response to any
nursing and medical care.

The focus charting system provides a holistic

perspective of the client and the client’s needs.
It also provides a nursing process framework
for the progress notes (DAR).
 The three components do not need
to be recorded in order
 Each note does not need to have all
three categories.
Flow sheets and checklists are frequently used
on the client’s chart to record routine nursing
tasks and assessment data.

D. Electronic health records (EHRs)

- Used to manage the huge volume of information required in contemporary health care. That is, the EHR
can integrate all pertinent client information into one record. Nurses use computers to store the client’s database,
add new data, create and revise care plans, and document client progress.
- Some institutions have a computer terminal at each client’s bedside, or nurses carry a small handheld
terminal, enabling the nurse to document care immediately after it is given.
Multiple flow sheets are not needed in computerized record systems because information can be easily retrieved
in a variety of formats. For example, the nurse can obtain results of a client’s blood test, a schedule of all clients
on the unit who are to have surgery during the day, a suggested list of interventions for a nursing diagnosis,
a graphic chart of a client’s vital signs, or a printout of all progress notes for a client. Many systems can generate
a work list for the shift, with a list of all treatments, procedures, and medications needed by the client.
Computers make care planning and documentation relatively easy. To record nursing actions and client responses,
the nurse either chooses from standardized lists of terms or types narrative information into the computer.
Automated speech-recognition technology now allows nurses to enter data by voice for conversion to written
documentation.
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Again, according to HIPAA, if the spoken word

is used to create PHI, the nurse must be alert
and aware of others who might hear the
dictation.
The computerization of clinical records has
made it possible to transmit information from
one care setting to another. The Nursing
Minimum Data Set (NMDS) is an effort to
establish uniform definitions and categories
(e.g., nursing diagnoses) for collecting, essential
nursing data for inclusion in computer
databases.