Charting/Documenting (Nurses' Progress Report)

Nursing Procedure 2.5

Charting/Documenting (Nurses' Progress Report)

Facilitates comprehensive communication of relevant client data from one nursing caregiver to other nurses or members of health care team.

Small pad and pencil (for client summary notes)
Client Kardex or plan of care/clinical pathway
Client-specific progress note or nurses' note sheets
Computer (if using computerized charting system)
Pen (color per agency policy)

Assessment should focus on the following:

Previous notes from nurses, doctors, and other team members for an update on client status
Current status of client, as indicated by

Vital signs
Intake (infusion rates and amount remaining in tube feedings, IVs, and other infusions)
Output (drainage amounts)—indicate locations of tubes and drains
Dressings (degree and type of soiling, frequency of changes, and status of underlying skin/wound)
Treatments (number of times performed, duration, and client response)

Outcome Identification and Planning

Desired Outcomes

A sample desired outcome is:

Continuity of care is provided through dissemination of information in an accurate, comprehensive, and brief form.

Special Considerations in Planning and Implementation

General

Many facilities use computerized charting. It is important to use only the codes or passwords assigned to you individually to document on client records. NEVER allow someone else to document using your password. Ensure that the electronic charting is not being completed in a public location that would allow others to view the chart. Although the format is different for each system, the basic principles remain the same. Use computer checklists and client information data panels based on the instructions provided in the agency orientation to the system. Often you will need to document additional information that clarifies or amplifies the information provided in a computer; however, there may be a tendency to use only the basic checklists. When you need to provide more detailed information, always use the panels designated by the system for providing the information.

Charting must be complete regardless of the format. Assessment data should be obtained at the beginning of and throughout the shift and should be recorded in a small notebook until needed. Health care agencies may require that client data be recorded in a specialized format using the following categories: Subjective, Objective, Assessment, Planning, Implementation, and Evaluation. These categories may be used in whole (SOAPIE) or in part (SOAP, APIE). There are also other variations, such as Data-Action-Response (DAR); this form of charting includes subjective and objective data, implementation of actions, and evaluation of implementation to determine the degree to which the goals were met. Some agencies also include teaching with DAR charting (Data-Action-Response-Teaching [DART]) to ensure that teaching is adequately documented with consistency. Agency policies related to documentation of teaching should be followed. You may organize data in your notebook by indicating the type with an initial (e.g., A for Assessment or P for Planning). If routine client care flow sheets or checklists are used, then do not duplicate data. Use notes to record data not covered on flow sheets and to elaborate, if needed.

Home Health

Notations should be made for each care visit regarding the status of the homebound client. Content of notes should address how sick the client is. Report findings in objective and specific terminology. Notes should be directed toward justifying the reason for a home health visit.

[Outline]

Desired Outcomes
Special Considerations in Planning and Implementation
- General
- Home Health

Action		Rationale
1	Designate body systems that require detailed assessment and documentation.	Provides framework for concise charting, addressing only pertinent areas in great detail
2	Assess client in an orderly manner (see Nursing Procedure 3.7), and record findings in a small notebook.	Organizes notes and facilitates accuracy through minimum dependence on memory
3	When time allows, record initial client assessments in a chart (Table 2.1 lists guidelines).	Provides other health care team members with an update on pertinent client data
4	As the day progresses, record in a small notebook or bedside activity flow chart, if available, time of, precise details of, and client response to treatments or teaching. Also record occurrences pertinent to the client’s physical or mental state. For computerized charting, access the appropriate documentation panel and record information as designated by the computer system.	Indicates possible changes in client’s status requiring update in documentation; provides prompt and accurate recording of client data
5	Record pertinent observations in chart or on computer in an organized manner. USE ACTIVITY FLOW SHEETS, if available. Or use SOAPIE categories (in whole or in part) or other formats.	Promotes problem-oriented charting and organized, thorough documentation; eliminates repetition and shortens notes
6	Document any changes from initial assessment, or the absence of any changes, at least every 4 hr or according to client and agency policies.	Indicates ongoing nursing assessment and care
7	Use final note to highlight major shift events or progress toward goals.	Emphasizes priority shift occurrences and facilitates rapid review of notes
8	Document p.r.n. medication (medication given as necessary) in nurses’ notes per agency policy.	Demonstrates adherence to established policy
9	Adhere to the following legal guidelines in documentation:	Decreases indications of falsification or deception
	Never erase or scratch out errors in charting; instead, draw a line through the sentence and indicate the error with initials or according to agency policy.	Erasures and entries that have been scratched out are considered illegal entries, unacceptable in a court of law—Agency procedure must be followed for the entry to be considered legal or permissible as an acceptable entry
	Check for and correct small errors (e.g., wrong time or date).	Minimizes errors in charting that may decrease total credibility
	When recording events not witnessed or performed by you, use following form: “[name] reported administering or witnessing. . .”	Clarifies that recorder did not personally perform or view action
	Draw a line through space at end of completed notes.	Prevents someone else from adding information
	Sign notes before chart leaves your possession.	Avoids confusion of authorship should other people write on same form
	Chart actions on completion, not before performing them.	Avoids charting error due to delays in or cancellation of action
	Use complete words or acceptable abbreviations only (see Appendix B).	Eliminates miscommunication
	For computerized charting, never give out your password for someone to chart for you or for any other reason.	Prevents misuse; may be grounds for dismissal and has licensure implications; protects client privacy

Were desired outcomes achieved? An example of evaluation includes:

Desired outcome met: Continuity of care was provided through dissemination of information in an accurate, comprehensive, and brief form.

The following should be noted on the client's record:

Assessment data
Planning
Procedures performed and client's response
Evaluation

section name header

Purpose ⬇

Equipment ⬆ ⬇

Assessment ⬆ ⬇

Outcome Id ⬆ ⬇

Implementation ⬆ ⬇

Evaluation ⬆ ⬇

Documentation ⬆