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Documentation
Review types of clinical documentation
Professional documentation of a patient’s status is both a legal requirement and a professional
responsibility. It ensures continuity of care by providing written and permanent communication of patient
information. Hospital accreditation is dependent on sound basic documentation and nurses are legally
protected if their charting demonstrates that a professional standard of care has been delivered. Further,
documentation has educational and research applications as students and researchers can use the
information for scientific purposes.
There are many different types of documentation and charting, depending on the facility and the
circumstances. These include various flow sheets, assessment tools, incident forms, risk assessment
tools, discharge planning forms and nursing care planning forms. You need to become familiar with the
protocols for completing documents used at the facility where you are attending clinical practice. Although
principles of documentation apply to all patient documentation, this section will focus more on the
‘integrated progress’ or ‘nursing notes’, usually recorded at the end of each shift.
Patient-progress notes, depending on the facility’s choice, can be narrative, problem-oriented or
focused. As well, some facilities will have access to electronic documentation.
● Focus documentation is an holistic approach that makes the patient needs or problems the focus of
care. Nursing reports are organised using DAR (Data, Action and Response). Data includes
observation of patient status and behaviours. Action refers to nursing interventions and Response is
evaluating how the patient responds to the interventions. Problems are named (e.g. pain, nausea,
diarrhoea). Current practice in some areas uses a body systems approach (e.g. respiratory,
cardiovascular) or following the section headings in the nursing care plan to help structure the
content, and report relevant information. This type of documentation tends to be more nursingfocused and flexible, with specific information easier to find. Duplication of routine care recorded in
care plans or other charts should be avoided.
● Documentation by exception is used by some facilities. This mode of documentation focuses on
exceptions to the normal or deviations from the usual standards. These events are documented and
documentation continues until there is a return to the previous status or establishment of a new
level of wellbeing for the individual. Documentation by exception reduces the amount of time and
documentation required. Documentation by exception relies on nurses using the established flow
sheets, charting/graphic records, standard protocols and care plans or pathways so that continuous
appropriate care is provided and recorded as being delivered.
● Narrative documentation is simply recording what has happened as it happens, with the observations,
interventions, and the patient’s response to the interventions noted. This type of documentation is
being used less frequently.
Identify indications
Indications for documentation include admission or baseline notation of assessment and any changes in
the patient’s condition. The recording of accurate, complete and timely information is important, and helps
to ensure correct treatment is given by other nurses and other health professionals. Patients are in
hospital because their health condition is relatively unstable. Therefore, changes in their condition need to
be reported and documented. In the acute setting, hospital policy may permit a minimum of a written
report once every 24 hours, if there are no patient problems that require comment. In these situations,
ensure all care plans and other documents record care given and other patient data. Different
requirements apply for residential care settings.
Record content
Content of the documentation depends on the patient and their condition. For instance, someone who is in
hospital for a myocardial infarct would include documentation about pain levels, their circulation and
perfusion, and levels of anxiety. A person who has just had a surgical procedure like a knee replacement
would have different assessment parameters reported, such as peripheral circulation on the affected leg, pain
assessment of the site, drainage from the wound, and circulatory and respiratory status following anaesthetic.
Both patients would have notations about nursing interventions attended (e.g. repositioning, oxygen
administration, supporting the leg on a pillow, analgesic administration) and the patient’s response to these.
2.1
2.1 Documentation
46 PART 2: DOCUMENTATION
Tollefson, J., Tambree, K., Watson, G., Bishop, T., & Tollefson, J. (2016). Essential clinical skills : Enrolled nurses. ProQuest Ebook Central
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On admission to the unit, a thorough physical assessment and nursing history is documented as a
baseline. As each nurse takes over the care of the patient, their assessment of the patient at that time
should be noted. After that, alterations in the physical or psychosocial findings are noted. Use the patient’s
own words when possible when reporting subjective data.
Generally, changes in medical, physical, emotional or psychological condition are documented to alert
other health care professionals of potential complications (e.g. unrelieved leg or foot pain in the patient
with orthopaedic surgery to the leg).
Record response to treatment
Response to treatment, including analgesia or other prescribed medication, is important to note so that
ineffective treatment can be stopped or effective interventions continued. This might take the following
form. For example, ‘2400 – projectile vomiting of murky green fluid commenced 3 minutes following bolus
injection of IV antibiotic. Maxalon IV as per chart given with little effect; 0320 – vomiting lasted from 2410
to 0245 hours, sleeping at present; 0610 – again vomiting of clear green fluid began during bolus injection
of antibiotic medication; 0645 – vomiting continues, Dr Jones notified. Will review during morning rounds’.
You do not need to report the information that is charted on charts such as the Adult Observation and
Response Chart unless that information is relevant to other pertinent information you are recording, for
example, ‘0730 – patient found on the floor, pale, diaphoretic, states “felt dizzy”, BP 100/68, P. 58, BGL
2.3’. This uses both observed information and measured information to give a more complete picture.
Interventions and their effect that are not on other charts or assessment tools should be documented.
An example might be for a patient with fatigue: ‘Initial strategy for managing fatigue discussed. Able to
explain need to plan activities early in the day. Stated that “this makes sense” and will adopt this idea.’
Adhere to legal requirements for documentation
Because all patient documentation is a legal document, there are minimum standards that must be met.
Your entry must be:
● legible
● written in black ink
● dated using the dd/mm/yy system and timed using the 24-hour clock
● error-free or errors acknowledged with a single line through them and ‘error’ plus your initials
written above
● free of blank areas (draw a line through an unused portion of a line)
● written using plain language, without jargon. Abbreviations should not be used as they can lead to
errors and potential patient harm
● signed (this means that it was you who acted or observed – not someone else), with a printed name
and designation after the signature for identification purposes
● contemporaneous (i.e. made as close to the time of the observation or intervention as is reasonable).
A late entry must follow the last entry (do not try to squeeze additional information into the notes) and
be noted as such (i.e. use either ‘addit’ or ‘late entry’ beside the time you actually wrote the notation).
Include the time of the occurrence within the notation.
Only document care once it is given, and never pre-empt care. Correct spelling and grammar are
important because they make the entry readable. The entry should be factual, with specific information
(time of the occurrence; exact findings; the patient’s, doctor’s or your response), and objective, not
subjective. Do not interpret the facts, or use vague or tentative wording (e.g. appears, seems), do not use
the words ‘mistake’ or ‘accident’. Write what happened. Any change in the patient’s condition (physical,
medical, emotional, psychological) warrants a note in the chart. Assessments must also be specific.
Regularly update the patient’s progress notes and care plan. Failure to document care or record
patient observations/data is interpreted as care not being completed. Therefore, good documentation is
critical for every patient, not only for their safety and comfort, but also for the nurse’s security.
Become familiar with electronic documentation
As technological advances become more affordable, electronic record keeping in hospitals and health care
facilities will become more common. Much of the material presented on the previous page will be
applicable to electronic records. There are additional precautions – for example, since you cannot ‘sign’
2.1: Documentation 47
Tollefson, J., Tambree, K., Watson, G., Bishop, T., & Tollefson, J. (2016). Essential clinical skills : Enrolled nurses. ProQuest Ebook Central
Created from think on 2020-11-19 22:53:21.
Copyright © 2016. Cengage Australia. All rights reserved.
your note indicating that it was you who saw or did something, you will need to use a password and PIN
that will be unique to you and you will need to guard it carefully. Errors in data entry will still have to be
acknowledged and left in the record.
Transmitting documentation from one facility to another or from the doctor’s office to a facility,
laboratory or other external provider requires the nurse to be aware of ensuring security of information,
confidentiality and transmissibility of materials. The facility where you are working will have protocols for
moving and photocopying material from a patient’s chart to another setting.
Note: These notes are summaries of the most important points in the assessments/procedures, and are not exhaustive on the subject. References of the
materials used to compile the information have been supplied. The student is expected to have learned the material surrounding each skill as presented
in the references. No single reference is complete on the subject.
References
Australian Commission on Safety and Quality in Health Care. (n.d.). Australian Safety and Quality Framework for Health Care. Putting the
Framework into Action: Getting Started. Retrieved from http://www.safetyandquality.gov.au/national-priorities/australian-safety-and-qualityframework-for-health-care.
Dougherty, L. & Lister, S. (eds). (2011). The Royal Marsden Hospital Manual of Clinical Nursing Procedures (8th ed.). Oxford: Wiley-Blackwell.
Smith, S. F., Duell, D. J. & Martin, B. C. (2012). Clinical Nursing Skills: Basic to Advanced Skills (8th ed.). Upper Saddle River, NJ: Prentice Hall.
Stanhope, J. (2014). Healthcare Documentation: Abbreviations. Joanna Briggs Institute.
| CA | SE STUDY |
| Mrs Anya Diangello is a 78-year-old lady you are caring for this shift. She is a frail lady with a history of osteoarthritis. She has been admitted for management of a recent episode of bronchitis that has made her quite unwell. Mrs Diangello has poor skin turgor (due to age-related changes) and normally mobilises with a walking frame (Zimmer frame). She normally has some independence in her personal activities of daily living (ADLs) at home and has assistance from Home and Community Care Services with meals on wheels, and domestic help in the house. During this admission she currently requires nursing assistance in the shower, to get out of bed and with her mobility. 1. Using a nursing care plan from your facility, create a nursing care plan for Mrs Diangello. Review the above information plus any further information about bronchitis and relevant nursing care actions to include in the nursing care plan. While assisting Mrs. Diangello in the shower this morning she experienced an episode of shortness of breath and dizziness. Her pulse and respirations were elevated (P: 92, R: 22, BP: 110/80) and her oxygen saturations dropped slightly (94%, previously 96–98%). You returned her to bed, gave her oxygen and notified the RN. Her condition then improved and she has otherwise been her usual self today. The doctor was also notified and has reviewed Mrs Diangello. 2. Follow the principles of ‘focus documentation’ and ‘documentation by exception’ to complete an end of shift report for |
|
| the a docu |
m/morning shift for Mrs Diangello. Remember to incorporate information from other charts, care plans and ments that also have recorded some of the data about Mrs Diangello’s care and health status. |
AssignmentTutorOnline
48 PART 2: DOCUMENTATION
Tollefson, J., Tambree, K., Watson, G., Bishop, T., & Tollefson, J. (2016). Essential clinical skills : Enrolled nurses. ProQuest Ebook Central
Created from think on 2020-11-19 22:53:21.
Copyright © 2016. Cengage Australia. All rights reserved.
ESSENTIAL SKILLS COMPETENCY
DOCUMENTATION
Demonstrates the ability to accurately record information about a patient in a timely manner
| Criteria for skill performance (Numbers indicate ANMC National Competency Standards for the Enrolled Nurse, 2002) 1. Identifies indications for documentation in the patient’s chart/record (4.1, 7.1, 8.1) 2. Uses appropriate medical terminology and approved abbreviations and acronyms (1.1, 1.2, 2.2, 5.2, 8.1) 3. Content is relevant and accurate (1.2, 1.3, 1.4, 1.5, 2.2, 4.1, 5.3, 7.1, 7.3, 8.1) 4. Adheres to legal requirements (1.1, 1.3, 1.4) 5. Demonstrates ability to effectively use facilities’ standard forms (1.1, 1.3, 1.4, 7.3) 6. Demonstrates an ability to link theory to practice (5.1, 5.2) |
Y (Satisfactory) |
D (Requires development) |
2.1: Documentation 49
Tollefson, J., Tambree, K., Watson, G., Bishop, T., & Tollefson, J. (2016). Essential clinical skills : Enrolled nurses. ProQuest Ebook Central
Created from think on 2020-11-19 22:53:21.
Copyright © 2016. Cengage Australia. All rights reserved.
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