109
9
Chapter Recording and
Reporting
W O R D S T O K N O W
auditors
beneficial disclosure change of shift report chart
charting
charting by exception checklist
computerized charting continuous quality
improvement documenting flow sheet focus charting Kardex
110 U N I T 3 ● Fostering Communication
Uses
Besides serving as a permanent health record, the collec- tive information about a client provides a means to share information among health care workers, thus ensuring client safety and continuity of care. Occasionally medical records also are used to investigate quality of care in a health agency, demonstrate compliance with national accreditation standards, promote reimbursement from insurance companies, facilitate health education and re- search, and provide evidence during malpractice lawsuits.
Permanent Account
The medical record is a written, chronologic account of a person’s illness or injury and the health care provided from the onset of the problem through discharge or death.
The record is filed and maintained for future reference.
Previous health records often are requested during sub-
sequent admissions so that the client’s health history can be reviewed.
Sharing Information
Because it is impossible for all health care workers to meet and to exchange information on a personal basis at the same time, the written record becomes central to com- munication (i.e., sharing information among personnel).
The documentation serves as a way to inform others about the client’s status and plan for care.
Sharing information prevents duplication of care and helps to reduce the chance of error or omission. For exam- ple, if a client requests medication for pain, the nurse checks the client’s chart to determine when the last pain- relieving drug was administered. Accurate and timely documentation prevents medication from being admin- istered too frequently or withheld unnecessarily. Main- taining immunization records is an example of how COMMON AGENCY CHART FORMS
TABLE 9-1
NAME OF FORM CONTENT
Fact sheet
Advance directive
History and physical examination
Physician’s orders
Physician’s or multidisciplinary progress notes Nursing admission data base
Nursing or multidisciplinary plan of care Graphic sheet
Daily nursing assessment and flow sheet Nursing notes
Medication administration record Laboratory and diagnostic reports Discharge plan
Teaching summary
Provides information such as the client’s name, date of birth, address, phone number, religion, insurer, admitting physician, admitting diagnosis, person to contact in case of emergency, emergency phone number
Provides instructions about the client’s choices for care should he or she be unable to make decisions later
Contains the physician’s review of the client’s current and past health problems, results of a body system examination, medical diagnosis, and tentative plan for treatment
Identifies laboratory and diagnostic tests, diet, activity, medications, intravenous fluids, and clinical procedures (instructions for changing a dressing, inserting tubes, and so forth) on a day-by-day basis
Describes the client’s ongoing status and response to the current plan of care, and potential modifications in the plan
Documents information concerning the client’s health patterns and initial physical assessment findings
Identifies client problems, goals, and directions for care based on an analysis of collected data
Displays trends in the client’s vital signs, weight, daily summary of fluid intake and output
Indicates focused physical assessment findings by individual nurses during each 24-hour period and the routine care that was provided
Provides narrative details of subjective and objective data, nursing actions, response of the client, outcomes of communication with other health care personnel or the client’s family
Identifies the drug name, date, time, route, and frequency of drug administration as well as the name of the nurse who administered each medication
Contains the results of tests in a sequential order
Indicates the information, skills, and referral services that the client may need before being released from the agency’s care
Identifies content that was taught, evidence of the client’s learning, and need for repetition or reinforcement
C H A P T E R 9 ● Recording and Reporting 111 documentation promotes continuity: the record ensures
the administration of subsequent immunizations accord- ing to an appropriate schedule.
Quality Assurance
To maintain a high level of care, hospitals and other health care agencies use medical records to promote quality assur- ance,continuous quality improvement, or total quality improve- ment(an agency’s internal process for self-improvement to ensure that the level of care reflects or exceeds estab- lished standards). One quality assurance method involves investigating the documentation in a sample of medical records. If the analyzed data indicate less-than-acceptable compliance with standards of care, the committee rec- ommends corrective measures and re-evaluates the out- comes later.
Accreditation
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is a private association that has established criteria reflecting high standards for institu- tional health care. Representatives of JCAHO periodi- cally inspect health care agencies to determine whether they demonstrate evidence of quality care.
The documentation in randomly selected medical records is just one component examined during an accreditation visit. As reported by Sheila Abood (2002), a representative of the American Nurses Association, JCAHO requires the following nursing documentation evidence to justify accreditation:
• Initial assessment and reassessments of physical, psy- chological, social, environmental, and self-care; educa- tion; and discharge planning
• Identification of nursing diagnoses or client needs
• Planned nursing interventions or nursing standards of care for meeting the client’s nursing care needs
• Nursing care provided
• Client’s response to interventions and outcomes of care, including pain management, discharge planning activities, and the client’s or significant other’s ability to manage continuing care needs
If documentation is substandard, JCAHO may withdraw or withhold accreditation.
Reimbursement
The costs of most clients’ hospital and home care are billed to third-party payers such as Medicare, Medicaid, and private insurance companies. Auditors (inspectors who examine client records) survey medical records to determine whether the care provided meets established criteria for reimbursement. Undocumented, incomplete, or inconsistent documentation of care may result in a denial of payment.
Education and Research
The primary resource for health education is textbooks.
Examining the medical records of clients with specific disorders, however, provides a valuable supplement that enhances learning and future problem solving. Client records also facilitate research. For example, some types of clinical investigations are difficult to conduct because few participants are in a particular locale or test facilities are limited. Consequently stored, microfilmed, or comput- erized medical records serve as an alternative resource for scientific data.
Nevertheless, to protect confidentiality, only autho- rized persons are allowed access to client records (see later discussion on protecting health information). Formal permission must be obtained from the client, the health agency’s administrator, or other authority whenever a client’s record is used for a purpose other than treat- ment and record keeping.
Legal Evidence
The medical record is considered a legal document. Por- tions of it can be subpoenaed as evidence by the defense or prosecuting attorney to prove or disprove allegations of malpractice. Therefore, written entries in medical records must follow legally defensible criteria (Box 9-1).
Each person who writes in the client’s medical record is responsible for the information he or she records and can be summoned as a witness to testify concerning what has been written. Any writing that cannot be clearly read or that is vague, scribbled through, whited out, written over, or erased makes for a poor legal defense.
Stop • Think + Respond BOX 9-1 Discuss how the nurse could improve each of the follow- ing documentation samples:
1. 01/11 0800 Ate well.
2. 1400 Hygiene provided and ambulated.
3. 1500 Depressed all day. S. Rogers
Client Access to Records
Historically clients were not allowed to see their medical records. Since the passing of federal legislation in 1996 known as the Health Insurance Portability and Account- ability Act (HIPAA), with further revisions in 2001 and 2002, however, clients have the right to see their own med- ical and billing records, request changes to anything they feel is inaccurate, and be informed about who has seen their medical records (Medcom Inc., 2003). Consequently many institutions have written policies that describe the guidelines by which clients can access their own medical
112 U N I T 3 ● Fostering Communication
records. Policies range from complete, unrestricted access on the client’s written request to arranging access in the presence of the client’s physician or hospital administrator.
Nurses must follow established agency policy.
Types of Client Records
Health records in most agencies contain similar informa- tion. They generally are organized in one of two ways:
either a source-oriented or a problem-oriented format.
Source-Oriented Records
The traditional type of client record is a source-oriented record(organized according to the source of documented information). This type of record contains separate forms on which physicians, nurses, dietitians, physical thera- pists, and other health care providers make written entries about their own specific activities in relation to the client’s care.
One of the criticisms of source-oriented records is that it is difficult to demonstrate a unified, cooperative approach for resolving the client’s problems among care- givers. Frequently the fragmented documentation gives the impression that each professional is working inde- pendently of the others.
Problem-Oriented Records
A second type of client record is the problem-oriented record
(organized according to the client’s health problems). In contrast to source-oriented records that contain numer- ous locations for information, problem-oriented records contain four major components: the data base, the prob- lem list, the plan of care, and progress notes (Table 9-2).
The information is compiled and arranged to emphasize goal-directed care, to promote recording of pertinent infor- mation, and to facilitate communication among health care professionals.
Nurses use various styles to record information within the client’s record. Examples include narrative notes, SOAP charting, focus charting, PIE charting, charting by excep- tion, and computerized charting.
Narrative Charting
Narrative charting(style of documentation generally used in source-oriented records) involves writing information about the client and client care in chronologic order.
There is no established format for narrative notations;
the content resembles a log or journal (Fig. 9-1).
Narrative charting is time-consuming to write and read. The caregiver must sort through the lengthy nota- tion for specific information that correlates the client’s problems with care and progress. Depending on the skill of the person writing the entries, he or she may omit pertinent documentation or include insignificant information.
METHODS OF CHARTING
COMMON COMPONENTS OF A PROBLEM-ORIENTED RECORD
TABLE 9-2
COMPONENT DESCRIPTION Data base
Problem list Plan of care Progress notes
Contains initial health information Consists of a numeric list of the
client’s health problems Identifies methods for solving each
identified health problem Describes the client’s responses to
what has been done and revisions to the initial plan
BOX 9-1 ● Criteria for Legally Defensible Charting
When making an entry on a client’s medical record, the nurse should
❙ Ensure that the client’s name appears on each page.
❙ Never chart for someone else.
❙ Use specified color of ink and ballpoint pen, or enter data on a computer.
❙ Date and time each entry as it is made.
❙ Chart promptly after providing care.
❙ Make entries in chronologic order.
❙ Identify documentation that is out of chronologic sequence with the words “late entry.”
❙ Write or print legibly.
❙ Use correct grammar and spelling.
❙ Reflect the plan of care.
❙ Describe the outcomes of care.
❙ Record relevant details.
❙ Use only approved abbreviations.
❙ Never scribble over entries or use correction fluid to obliterate what has been written.
❙ Draw a single line through erroneous information so that it remains readable, add the date, initial, and then document the correct information.
❙ Record facts, not subjective interpretations.
❙ Quote the client’s verbal comments.
❙ Write “duplicate” or “recopied” on documentation that is not original; include the date, time, initials, and reason for the duplication.
❙ Never imply criticism of another’s care.
❙ Document the circumstances for notifying a physician, the specific data reported, and the physician’s recommendations.
❙ Identify specific information provided when teaching a client and the evidence that indicates the client has understood the instructions.
❙ Leave no empty spaces between entries and signature.
❙ Sign each entry by name and title.
C H A P T E R 9 ● Recording and Reporting 113
SOAP Charting
SOAP charting(documentation style more likely to be used in a problem-oriented record) acquired its name from the four essential components included in a progress note:
• S=subjective data
• O=objective data
• A=analysis of the data
• P=plan for care
Some agencies have expanded the SOAP format to SOAPIE or SOAPIER (I =interventions, E =evaluation, R=revision to the plan of care) (Table 9-3).
Any variations in the SOAP format tend to focus the documentation on pertinent information. SOAP chart- ing also helps to demonstrate interdisciplinary coopera- tion because everyone involved in the care of a client makes entries in the same location in the chart.
Focus Charting
Focus charting(modified form of SOAP charting) uses the wordfocusrather than problem because some believe that the word problemcarries negative connotations. A focus can be the client’s current or changed behavior, significant
FIGURE 9-1
•
Sample of narrative charting. (Courtesy of Three Rivers Area Hospital, Three Rivers, MI.)114 U N I T 3 ● Fostering Communication
Computerized Charting
Computerized charting (documenting client information electronically) is most useful for nurses when a terminal is available at the point of care or bedside (Fig. 9-4). Hav- ing a terminal at the nursing station is a less desirable option because this removes the nurse from the source of the data; however, this may be the only alternative when there are limited computer modules available. Central- ized terminals generally are connected to large informa- tion systems that link departments in the institution (e.g., pharmacy, laboratory, admissions office, account- ing); therefore, they are less specific for nursing use.
Although each computer system varies, computerized charting generally is done by touching the monitor screen with a finger or using an electronic device such as a light pen to select from a list of menu options. Some sys- tems require entering data by using a keyboard, as a typ- SOAPIER CHARTING FORMAT
TABLE 9-3
LETTER EXPLANATION EXAMPLE OF RECORDING
S=Subjective information O=Objective information A=Analysis
P=Plan
I=Implementation E=Evaluation R=Revision
Information reported by the client Observations made by the nurse Problem identification
Proposed treatment Care provided Outcome of treatment Changes in treatment
S—“I don’t feel well.”
O—Temperature 102.4°F A—Fever
P—Offer extra fluids and monitor body temperature.
I—750 mL of fluid intake in 8 hours; temperature assessed every 4 hours
E—Temperature reduced to 101°F
R—Increase fluid intake to 1000 mL per shift until temperature is ≤100°F.
Bladder distended 2 fingers above pubis.
Has not urinated in 8 hrs. since catheter was removed.
Assisted to toilet. Water turned on at faucet. Instructed to press over bladder with hands.
Voided 525 mL of clear urine. L.Cass, SN 6/30/2007
1015
D(ata) –
A(ction) –
R(esponse) –
FIGURE 9-2
•
Example of DAR charting. FIGURE 9-3•
Sample of PIE charting.events in the client’s care, or even a NANDA nursing diag- nosis category. Instead of using the SOAP format to make entries, focus charting follows a DAR model (D =data, A=action, R =response) (Fig. 9-2). DAR notations tend to reflect the steps in the nursing process.
PIE Charting
PIE charting (method of recording the client’s progress under the headings of problem, intervention, and eval- uation) is similar to the SOAPIE format. The PIE style prompts the nurse to address specific content in a charted progress note.
When nurses use the PIE method, they document assessments on a separate form and give the client’s prob- lems a corresponding number. They use the numbers subsequently in the progress notes when referring to interventions and the client’s responses (Fig. 9-3).
Charting by Exception
Charting by exceptionis a documentation method in which nurses chart only abnormal assessment findings or care that deviates from the standard. Proponents of this effi- cient method say that charting by exception provides quick access to abnormal findings because it does not describe normal and routine information.
C H A P T E R 9 ● Recording and Reporting 115
ist would do, or by using a combination of keyboarding and touch-screen technology. Data entry by voice activa- tion is on the horizon. A single keystroke saves the infor- mation displayed on the monitor to the client’s record (Fig. 9-5).
Computerized charting has many advantages:
• The information is always legible.
• It automatically records the date and time of the documentation.
• The abbreviations and terms are consistent with agency- approved lists.
• It eliminates trivia.
• Omissions are fewer because the computer prompts the nurse to enter specific information.
• It saves time because it eliminates delays in obtaining the chart.
• It reduces overtime costs for uncompleted end-of-shift charting.
• Electronic data require less storage space and are quickly retrievable.
The major disadvantages include the initial expense of purchasing a computer system and training personnel to use it. In addition, during a power failure or electronic malfunction, nurses must resort to written documenta- tion until the emergency backup access reactivates the computer system.
Besides charting, other computer applications benefit nursing. Computers are being used to generate nursing care plans, develop staffing patterns that meet the cur- rent unit census and client acuity levels, analyze assess- ment data from monitoring equipment, call attention to drugs that have been newly ordered or not administered, and alert the nurse to incompatibilities or contraindica- tions to prescribed drugs.
Congress enacted the first HIPAA legislation to protect the rights of U.S. citizens to retain their health insurance when changing employment. To do so required trans- mitting health records from one insurance company to another. Transmission of the information resulted in the disclosure of personal health information to nonclinical individuals, a process that, in essence, jeopardized the individual’s right to privacy. Subsequently the original HIPAA legislation was expanded in 2001 and 2002 to enact further measures to protect the privacy of health records and the security of that data. All health care agen- cies have been mandated to comply with the newest HIPAA regulations since 2003.
Privacy Standards
HIPAA regulations require health care agencies to safe- guard written, spoken, and electronic health information in the following ways:
1. Submit a written notice to all clients identifying the uses and disclosures of their health information such as to third parties for use in treatment or pay- ment for services.
2. Obtain the client’s signature indicating that they have been informed of the disclosure of information and their right to learn who has seen their records.
The law also indicates that agencies must limit released information from a health record to min- imum disclosure, or information necessary for the immediate purpose only. In other words, it is inap- propriate to release the entire health record when only portions or isolated pieces of information are needed.
Health care agencies must obtain specific authorization from the client to release information to family or friends, attorneys, and other uses such as research, fundraising, and marketing. The client retains the right to withhold health information for any of these. There are some excep- tions when health information can be revealed without the client’s prior approval. Box 9-2 identifies examples of
beneficial disclosures(exemptions when agencies can release private health information without the client’s prior authorization).
Workplace Applications
In an effort to limit casual access to the identity of clients and health information, HIPAA legislation has created several changes that affect the workplace. Some exam- ples of these regulations include the following:
• The names of clients on charts can no longer be visible to the public.