CHAPTER 15 / Documenting and Reporting 71
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List the measures used to maintain the confidentiality and security of
computerized client records.
Concepts for Lecture
1. Access to the client’s health information is restricted to health pro-
fessionals involved in giving care to the client. The institution or
agency is the rightful owner of the client’s record. However, the cli-
2. The following are some suggestions for ensuring confidentiality and
security of computerized records:
• A personal password is required to enter and sign off computer
files.
• Personal passwords should not be shared.
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2
Discuss purposes for client records.
Concepts for Lecture
1. Client records are kept for a number of purposes: communication,
planning client care, auditing health agencies, research, education,
reimbursement, legal documentation, and health care analysis.
Client records serve as a vehicle by which health professionals
C
HAPTER
15
DOCUMENTING AND REPORTING
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• Invite a speaker who is an administrator or
lawyer to discuss the importance of maintaining
confidentiality in client records.
•
Invite a speaker from an institution’s
information technology department to discuss
computer security for clients’ records.
The information contained in the record can be a valuable source
of data for research. Treatment plans for clients with the same
diagnosis can yield information helpful in treating other clients.
contain the correct diagnostic-related group (DRG) codes and reveal
that the appropriate care has been given.
Other insurance companies and other third–party payers also
require appropriate documentation for reimbursement. If additional
care, treatment, or length of stay becomes necessary for the client’s
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3
Compare and contrast different documentation methods: source-oriented and
problem-oriented medical records, PIE, focus charting, charting by exception,
computerized records, and the case management model.
Concepts for Lecture
1. In the source-oriented record, the traditional client record, each
which consists of written notes that include routine care, normal
findings, and client problems, often in chronological order.
Source-oriented records are convenient and disciplines can
2. In the problem–oriented medical record (POMR) or problem-
oriented record (POR), the data are arranged according to the
problem the client has rather than the source of the information.
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• Give students a database about a client in a
clinical setting. Have them document infor-
mation from the database using several different
documentation methods.
•
Obtain documentation forms from several
institutions. Compare and contrast the
methods used.
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•
Examine a client record and compare documen-
tation by nurses, primary care providers, and
uses computerized records. Discuss with the
staff members who use the system the ad-
vantages and disadvantages over handwritten
records.
importance of documentation in reference to
their responsibilities.
3. The PIE documentation model groups information into three catego-
ries: Problem, Interventions, and Evaluation of nursing care. It con-
4. Focus charting is intended to make the client and the client’s con-
cerns and strengths the focus of care. The focus may be a condition,
5. Charting by exception (CBE) is a documentation system in which
any abnormal or significant findings or exceptions to norms are
recorded. CBE incorporates three elements: flow sheets, standards of
6. Computerized documentation systems are being developed to
manage the huge volume of information required in contemporary
7.
The case management model emphasizes quality, cost-effective care
delivered within an established length of stay. It uses a multidisciplinary
approach to planning and documenting client care, using critical
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Explain how various forms in the client record (e.g., flow sheets, progress
notes, care plans, critical pathways, Kardexes, discharge/transfer forms) are
used to document steps of the nursing process (assessment, diagnosis,
planning, implementation, and evaluation).
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•
Obtain copies of the documentation forms used
in the institution. Ask the students to locate
where the various components of the nursing
process are documented.
74 CHAPTER 15 / Documenting and Reporting
Concepts for Lecture
1. The client record should describe the client’s ongoing status and
reflect the full range of the nursing process.
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5
Compare and contrast the documentation needed for clients in acute care,
long-term care, and home health care settings.
Concepts for Lecture
1. Requirements for documentation in long–term care settings are based
on professional standards, federal and state regulations, and policies
2. General guidelines for long–term care documentation include:
• Complete the assessment/screening forms (MDS) within the time
period specified by regulatory bodies
• Keep a record of any visits and of phone calls from family,
3. In 1985 the Health Care Financing Administration mandated that
home health care agencies standardize their documentation methods
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UGGESTIONS FOR
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• Invite nurses from a home health care agency
and a long-term care setting to discuss the
documentation process required in these agen-
cies.
•
Obtain forms used by home health care
agencies and long-term care settings for doc-
umentation. If possible obtain the policies and
procedures for documentation in these
4. Guidelines for home care documentation include:
• Complete the comprehensive nursing assessment and develop plan
of care to meet Medicare and other third-party payers
• Write progress notes at each visit noting any change in client’s
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Discuss guidelines for effective recording that meets legal and ethical
standards.
Concepts for Lecture
1. Because the client’s record is a legal document and may be used to
2. Factors to be considered include timing, legibility, permanence,
accepted terminology, correct spelling, signature, accuracy,
sequence, appropriateness, completeness, conciseness, and legal
prudence.
done before providing the care.
• Legibility: All entries must be legible and easy to read. Printing or
easily understood handwriting is usually permissible. Follow
• Correct spelling: Correct spelling is essential for accuracy in
recording. If unsure how to spell a word, look it up in a dictionary
or other resource book.
• Signature: Each recording is signed by the nurse making it, includ-
ing name and title. Some agencies have a signature sheet and after
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UGGESTIONS FOR
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• Provide examples of errors in charting. Divide
the students into groups and have each group
determine and demonstrate the best way to
correct the errors in a clear and legal manner.
Share the groups’ corrections with the class and
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notes using the guidelines for documentation
in the text.
preted differently. When a mistake in recording has been made,
draw a line through it and write the words mistaken entry above or
next to the original entry, with your initials or name (follow agen-
cy policy). Do not erase, blot out, or use correction fluid. Follow
agency policy for correcting documentation errors in computerized
and helpful to the client and health care professionals. Nurses’
notes need to reflect the nursing process. Care that is omitted
because of the client’s condition or refusal of treatment must also
be recorded, including what was omitted, why it was omitted, and
who was notified.
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Identify prohibited abbreviations, acronyms, and symbols that cannot be used
in any form of clinical documentation.
Concepts for Lecture
1. In 2004, The Joint Commission’s developed National Patient Safety
Goals (NPSGs) to reduce communication errors. These goals are
required to be implemented by all organizations accredited by The
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UGGESTIONS FOR
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• Review the information in Table 15–5 with the
students, stressing the rationale for inclusion on
the “Do Not Use” list.
•
Provide examples of how these terms can be
misinterpreted.
CHAPTER 15 / Documenting and Reporting 77
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Identify essential guidelines for reporting client data.
Concepts for Lecture
1. The purpose of reporting is to communicate specific information to a
2. Key elements of a change–of–shift report include the following:
follow a particular order (e.g., room numbers); provide basic identi-
3. Health professionals frequently report about a client by telephone.
Nurses inform primary care providers about a change in a client’s
condition. A nurse may report to another nurse on another unit about
a transferred client. The nurse receiving a telephone report should
4. Primary care providers often order therapy for a client by telephone.
Most agencies have specific policies about who may take such an
order, as may state nursing boards. Guidelines for taking telephone
orders include: know the state nursing board’s position on who can
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UGGESTIONS FOR
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•
Divide the students into groups. Have each
group role-play a change-of-shift report, a tel-
ephone report to a physician, and a transfer
report to another unit using data that you pro-
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•
Review the institution’s policies and procedures
for taking verbal orders and reports.
5. A care plan conference is a meeting of nurses to discuss possible
solutions to certain problems. Other health professionals may be
6.
Nursing rounds are procedures in which two or more nurses visit
selected clients at the bedside to obtain information that helps plan nurs-