Documenting, Reporting, Conferring, And Using Informatics

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Nursing care rounds are procedures in which a group of nurses visits select clients individually at each client’s bedside. The primary purposes are to gather information to help plan and evaluate nursing care and to provide the client with an opportunity to discuss care.

The POMR is organized around a client’s problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care.

When recording an error in documentation, the nurse should always cross out the incorrect statement with a single line so that it remains readable, add the date, initial, and then document the correct information. The nurse should not erase the incorrect statement and replace it with the correct one, nor cross out the wrong statement in a way that makes the statement unreadable, nor use correction fluid to obliterate what has been written. These methods render the medical record a poor legal defense.

An incident report, also termed a variance or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a client, employee, or visitor. Incident reports should not be used for disciplinary action against staff members.

The nurse should strike out the erroneous entry with a single line and place initials over it. When an error occurs, erasure or use of correction fluid is not permissible. Use of highlighters is not allowed and can draw attention to the erroneous documentation.

The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a complaint of pain. The nurse’s objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.

The client record is the only permanent legal document that details the nurse’s interactions with the client. It is the best defense if a client or client surrogate alleges nursing negligence.

Students using client records are bound professionally and ethically to keep in strict confidence all the information they learn from those records. The student may discuss care with the instructor, medications with a staff nurse, and laboratory data with the physician. The student should not use actual client names or other identifiers in written assignments or oral reports.

According to the ANA Scope and Standards of Nursing Informatics Practice, nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support clients, nurses, and other providers in their decision making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology (ANA, 2001, p. vii).

The medical history, physical examination, and progress notes record the findings of physicians as they assess and treat the client. They focus on identifying pathologic conditions and their causes, as well as determining the medical regimen for treatment.

Source-oriented documentation is a record organized according to the source of documented information. This type of record contains separate forms on which health care personnel make written entries about their own specific activities in relation to the client’s care. The problem-oriented method of recording demonstrates a unified, cooperative approach to resolving the client’s problems. Source-oriented records are organized at numerous locations; there is not one location for information. The problem-oriented record is compiled to facilitate communication among health care professionals.

The most accurate entry would be "Client states pain is a 9 on a scale of 1 to 10." This entry provides a specific and quantifiable measure of the client's pain intensity, allowing for a more accurate assessment and comparison over time. The other options provide subjective descriptions of the client's pain but do not provide a clear indication of the intensity level.

ISBARR communication is an increasingly common tool for interdisciplinary communication. It is not typically used during change-of-shift report nor when communicating with family members. ISBARR is considered a framework for communication rather than a format for documentation.

The nurse should record client findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as “good,” “average,” “normal,” or “sufficient,” which may mean different things to different readers.

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Among the JCAHO’s list of “do not use” abbreviations are Q.D., qd, and OD when denoting a once-per-day drug administration. Because of the potential for misinterpretation and consequent drug errors, the JCAHO recommends writing “daily” in the order.

The nurse should come prepared with material required to take notes during the change-of-shift reports. The nurse should not delay the meeting for change-of-shift report by paying courtesy calls to staff members before attending the meeting. Change-of-shift reports are not conducted in the presence of physicians, thus the nurse does not need to wait for the physicians to arrive before exchanging notes. The nurse should ask questions related to the medical record if any information is unclear.

One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

Each entry is signed with the first initial, last name, and title. In this case, A. Jones, RN, is correct.

Charting by exception is least likely to hold up in court if a case of negligence is brought against a nurse. This method involves documenting only significant findings or exceptions to the normal condition of the client. It does not provide a comprehensive record of the client's condition and the care provided. In a legal case, a thorough and detailed documentation is essential to prove that the nurse provided appropriate care and followed established protocols. Charting by exception may be seen as insufficient evidence of the nurse's actions and decision-making, which could weaken their defense in court.

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A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation, and both standardization of charting and identification of client-specific problems are possible within this documentation framework.

The phrase "up ad lib" means that the client is allowed to be up and engage in activities as desired. This indicates that there are no restrictions on their activity level and they are free to move around and participate in any activities they choose.

The nurse should use ISBAR to communicate verbally to the health care provider. Identify/Introduction, Situation, Background, Assessment, and Recommendation (ISBAR) is the communication tool to provide critical client information to the health care provider. EMAR is Electronic Medication Administration Record, which documents medication administration. SOAP is Subjective, Objective, Assessment, and Plan, which is a progress note that relates to only one health problem. CBE is Charting by Exception and permits the nurse to document only those findings that fall outside the standard of care and norms that have been developed by the institution.

The SOAP format (subjective data, objective data, Assessment [the caregiver’s judgment about the situation], plan) is used to organize data entries in the progress notes of the POMR. A client complaint of pain is subjective data (S).

Long-term care documentation is specified by the RAI with the minimum data set forming the foundation for the assessment. This is required in all facilities certified to participate in Medicare or Medicaid. OASIS is used in the home health care industry

In the PIE notes, the nurse documents the problem, intervention and evaluation. Thus the nurse would document the intervention carried out. Client assessment is not a part of the PIE notes, because this information is recorded on flow sheets for each shift. Although the PIE system uses a nursing plan-of-care format, there is no written plan of care. The PIE system is not multidisciplinary; it provides a documentation system for nursing only.

A narrative note in a skilled nursing facility might include the type of morning care, nutritional intake, client activity pattern, and comfort measures provided, along with the client’s response.

Nurses may use computers to document client data as long as they are not in a public area, and as long as the computer is shut down following the entries. A nurse can also check the medical record for a relative to call in case of an emergency. All the other examples are violations of client confidentiality.

A source-oriented record is a type of documentation method where a nurse would document narrative notes in a nursing section. In this method, the nurse organizes the patient's medical information according to its source, such as separate sections for nursing notes, physician notes, laboratory reports, etc. This allows for easy retrieval of information by different healthcare professionals involved in the patient's care.

The SOAP method begins by selecting a problem from a list. PIE (problems, interventions, and evaluation) notes incorporate the plan of care into the progress notes. Focus DAR notes organizes entries by data, action, and response. The narrative notes are used to record relevant client and nursing activities throughout a shift

The graphic record is a form used to document specific client variables such as vital signs, weight, intake and output, and bowel movements.

The nurse should empathize with the client to perceive how the client is feeling. The nurse shares his or her perception with the client, which makes him comfortable to share his anxieties, fear, and concerns. The first response conveys pity on the client, which is inappropriate. In the third response, the nurse is taking the side of the nursing staff and the client may not like it. The fourth response is nontherapeutic.

Documentation in a timely manner can help avoid errors.

The words “unit”, “daily”, “greater than” and “less than” should be spelled out. NPO, mL, and mcg are acceptable abbreviations.

Standardized care plans that identify common problems and needs with relation to select client cohorts may be used. Unless such care plans are individualized to a specific client, however, they may not address individual client needs.

Permitted incidental disclosures of PHI include using sign-in sheets without the reason for visit; the possibility of a conversation being overheard if measures are taken to be private; placing a client chart on the door with the face pages facing inward; placing an x-ray on a light board as long as it is not unattended; calling the name of a waiting patient; and leaving appointment reminders on answering machines (provided only a minimal amount of information is given).

A progress note should be written in the following instances: upon admission, transfer to another unit, and discharge; when a procedure is performed; upon receiving a client postoperatively or postprocedure; upon communicating with physicians regarding critical client information (e.g., abnormal lab value result); or for any change in client status.