Documentation

1
Documentation

• Recording and Reporting

2
Communication in health care

1. Discussion
2. Reporting
3. Oral
4. Written
5. Taped
6. Charting

3
Recording The Chart

• Patients health care information
• Purposes
• Communication
• audit
• research
• education

4
Recording The Chart

• Nursing documentation
• Assessment
• Care plan
• Narrative notes
• Flow sheets
• Medication records (MAR)
• Discharge summary
• Incident report is not part of the chart

5
Guidelines for Documentation

• Content
• Format
• Timing

6
Problem-oriented record

• S-O-A-P-I-E-R
• A-P-I-E

7
Source-oriented record

• Separate form for each group
• Nurses notes are usually narrative
• Flow sheets used extensively

8
Care Paths

• Also known as
• Critical paths
• MAPS
• Charting by exception

9
Computer documentation

• Electronic transmission to regulatory agencies
• Purchasers of health care demanding evidence of
  quality
• Nursing leaders calling for outcomes database
• Managed care organizations want to track the
  client across continuum of care

10
Reporting

• Forms
• Change of Shift
• Basic Identifying data
• Current health status
• Orders
• Summary
• Transfer/DC