HEALTH ASSESSMENT

DOCUMENTING AND REPORTING

1. Discussion
 Informal oral consideration of a subject by two or more health care personnel to identify a problem or
establish strategies to resolve a problem
2. Report
 Oral, written, or computer-based communication intended to convey information to others.
3. Record
 Written or computer based
 Recording/Charting/Documenting
o Process of making entry on a client record.
4. Chart
 Client record/clinical record
 Formal, legal document that provides evidence of a client’s care.
5. Joint Commission on Accreditation of Healthcare Organization (JCAHO)
 Requires client record documentation to be:
o Timely
o Complete
o Accurate
o Confidential
o Specific

ETHICAL AND LEGAL CONSIDERATIONS

1. ANA Code of Ethics (2001) states that:

 “… the nurse has a duty to maintain confidentiality of all pt information”
o Client’s record is also protected legally as private record of the client’s care.
o Access to the record is restricted to the Health professionals involved in giving care to the client.
o Institution or agency is the rightful owner of the client’s record.
2. April 14, 2003
 New Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulation maintain privacy
and confidentiality of Protected Health Insurance (PHI)
o PHI is identifiable health information that is transmitted or maintained in any form or medium.
o For purposes of education and research, most agencies allow students or graduate health
professionals access to client records.
 Bound by a strict ethical code and legal responsibility to hold all information in
confidence.
 USE PSEUDONAME

PURPOSES OF CLIENT RECORDS

1. Communication
 Serves as the vehicle by w/c different health professionals who interact with a client communicate with
one another.
2. Planning Client Care
 Uses data from the client’s record to plan care to the client
 Nurses use baseline data or ongoing data to evaluate the effectiveness of the nursing care plan.
3. Auditing Health Agencies
 Audit is a review of client records for quality-assurance purposes.
  JCAHO may review client records to determine if a particular health agency is meeting its stated
standards.
4. Research
 Treatment plans for a number of clients with the same health problems can yield information helpful in
treating other clients.
5. Education
 Use clients’ records as educational tools.
 Record can frequently provide a comprehensive view of the client, the illness, effective treatment
strategies and factors that affect the outcome of the illness.
6. Reimbursement
 Helps the facility receive reimbursement from the federal government.
7. Legal Documentation
 Legal document and is usually admissible in court as evidence.
8. Health Care Analysis
 Information from records may assist health care planners to identify agency needs, such as overutilized
and underutilized hospital services.

DOCUMENTATION SYSTEMS

1. Source-Oriented Record
 Traditional client record
 Each person/department makes notations on separate sections of the clients’ chart.
o Example:
 Admission department = admission sheet
 Physician = physician’s sheet
 Nurse = nurses’ notes
 Information is about a particular problem is distributed throughout the record.
 NARRATIVE CHARTING
o Traditional part of the Source-Oriented Record
o Consists of written notes that include:
 Routine care
 Normal findings
 Client problems
o Chronological order is used
o Expedient (advisable) in emergency situations.
o When using this, it is important to organize the information in a clear, coherent manner
o Nursing process as a framework.
 Convenient because:
o Care providers from each discipline can easily locate the forms on w/c to record data
o It is easy to trace the information specific to one’s discipline.
 Disadvantage because:
o Information about particular client problem is SCATTERED throughout the chart, so it is difficult
to find chronological information
o Decrease communication among health team
o Incomplete picture of the client’s care
o Lack of coordination of care.
2. Problem-Oriented Medical Record (POMR)
 Established by Lawrence Weed in 1960s
 Data are arranged according to the problems the client has rather than the source of the information.
 Members contribute to the problem list, plan of care, and progress notes.
 Advantages:
o It encourages collaboration
o The problem list in the front of the chart alerts caregivers the client’s needs
o Makes it easier to track the status of each problem.
 Disadvantages:
o Caregivers differ in their ability to use the required charting format
o It takes constant vigilance to maintain up-to-date problem list
o It is somewhat inefficient because assessment and interventions that apply to more than one
problem must be repeated.
 It has four (4) basic components:
o Database
o Problem List
o Plan of Care
o Progress Notes
 In addition, flow sheets and discharge notes are added to the record as needed.
a) Database
 Consists of ALL information known about the client when the client first enters the health
care agency.
 Nsg Assessment, physician’s history, physical examination, etc.
b) Problem List
 Derived from the database
 Kept at the front of the chart and served as an index to the numbered entries on the
progress notes.
 Problems are listed in the order in w/c they are identified, and the list is continually updated
as new problem are identified and others resolved.
 All caregivers may contribute on the client’s problem list, w/c includes:
 Physiologic needs
 Psychologic needs
 Social needs
 Cultural needs
 Spiritual needs
 Developmental needs
 Environmental needs
 Primary care providers write problems as MEDICAL DIAGNOSES, SYMPTOMS
Nurses write problems as NURSING DIAGNOSES
 When a problem is solved, a line is drawn through it and the number is not used again for
that client.
c) Plan of Care
 Initial list of orders
 Reference to the active problems.
d) Progress Notes
 Chart entry made by all health professionals involved in a client’s care
 All use the same type of sheet for ntoes.
 Numbered to correspond to the problems on the problem lists and may be lettered for the
type of data.
 SOAP (Subjective, Objective, Assessment, and Plan) format is frequently used.
 It has been modified into:
  SOAPIE (Subjective, Objective, Assessment, Plan, Intervention, and
Evaluation)
 SOAPIER (Subjective, Objective, Assessment, Plan, Intervention, Evaluation,
and Revision)
 Newer version where the Subjective and Objective data is eliminated and it is
included in the Assessment part:
 AP (Assessment and Plan)
 APIE (Assessment, Plan, Intervention, and Evaluation)
 APIER (Assessment, Plan, Intervention, Evaluation, and Revision)
3. PIE (Problem, Intervention, and Evaluation)
 Consists of a client care assessment flow sheet and progress notes.
 FLOW SHEET
o Uses specific assessment criteria in a particular format, such as:
 Human needs
 Functional health patterns
o Time parameter can vary from minutes to months.
 Example:
 ICU pt’s blood pressure may be monitored by the minute
 Ambulatory clinic, pt’s blood glucose lvl may be recorded once a month.
 After assessment, the nurse established and records specific problems on the progress notes, often
using NANDA diagnoses.
o If there is no approved nsg diagnoses, nurse develops a problem statement using NANDA’s
three-part format:
 Client response
 Probable causes of response
 Characteristics manifested by the client
 Problem statement is labeled “P” and referred to by number (P #5)
 Interventions employed to manage a problem are labeled “I” and numbered acc. To problem (I #5)
 Evaluation of the effectiveness of the interventions is also labeled and numbered acc. To the problem (E
#5)
 PIE SYSTEM eliminates the traditional care plan and incorporates an ongoing care plan into the progress
notes.
 Disadvantage:
o Nurse must review all the nursing notes before giving care to determine w/c problems are
current and w/c interventions were effective.
4. Focus Charting
 Intended to make the client and client concerns and strengths the focus of care.
 Three columns for recording are used:
o Date and time
o Focus
o Progress Notes
 FOCUS may be a condition, nsg diagnosis, a behavior, sign or symptom, an acute change in the client’s
condition, or a client strength.
 PROGRESS NOTES are organized into: DAR
o Data – reflects the assessment phase
o Action – planning and implementation
o Response – evaluation phase
 Provides HOLISTIC PERSPECTIVE of the client and the client’s needs.
  Provides a nursing process framework for the progress notes.
5. Charting by Exception
 Documentation system in which only abnormal or significant findings or exceptions to norms are
recorded.
 FLOW SHEETS
o Graphic record, fluid balance record, daily nursing assessment record, client teaching record,
client discharge record, and skin assessment record
 STANDARDS OF NURSING CARE
o Documentation of care according to the specified standards involves only a check mark in the
routine standards box on the graphic record.
 If all of the standards are not implemented, an ASTERISK on the flow sheet is made with
reference to the nurses’ notes.
 BEDSIDE ACCESS TO CHART FORMS
o All flow sheets are kept at the client’s bedside to allow immediate recording.
 Advantage:
o Elimination of lengthy, repetitive notes
o It makes client changes in condition more obvious
 Inherent presumption in CBE is that the nurse DID ASSESS the client and determined what responses
were normal and abnormal.
 Many nurses believe in the saying “NOT CHARTED, NOT DONE”, and subsequently feel uncomfortable
with the CBE documentation system.
 Writing N/A on flow sheets where the items are not applicable and to not leave blank spaces.
o This would avoid misinterpretation that the assessment or intervention was not done by the
nurse.
6. Computerized Documentation
 Developed as a way to manage the huge volume of information required in contemporary health care.
 Nursing Minimum Data Sheet (NMDS) is an effort to establish standards for collecting standardized,
essential nursing data for inclusion in computer databases.
7. Case Management
 Emphasizes quality, cost effective care delivered within an established length of stay.
 Uses a multidisciplinary approach to planning and documenting client care, using critical pathways.
o These forms identify outcomes that certain group of clients are expected to achieve on each day
of care, along with the interventions necessary for each day.
 If goals are MET, no further charting is required.
If goals are NOT MET, it is called a variance, and it is a deviation to what is planned on the critical
pathway.
 This model promotes:
o collaboration and teamwork among caregivers,
o Helps to decrease length of star
o Makes efficient use of time
 Because care is GOAL FOCUSED, the quality may improve.
 Critical pathways work best with one or two diagnoses and few individualized needs.

DOCUMENTING NURSING ACTIVITIES

1. Admission Nursing Assessment

 Comprehensive admission assessment/initial database/nursing history/nursing assessment
 Completed when the client is admitted to the nursing unit.
2. Nursing Care Plans
  2 types of nursing care plans:
o Traditional care plan = written for each client; 3 columns (nsg diagnoses, expected outcomes,
nsg interventions)
o Standardized care plan = developed to save documentation time.
3. Kardexes
 Widely used, concise method of organizing and recording data about a client, making information
quickly accessible to all health professionals.
 Consists of series of cards kept in a portable index file or on computer-generated forms.
 Written in pencil for ease in recording frequent changes in details of a client’s care.
 Information on Kardexes:
o Pertinent information about the client
o Allergies
o List of medication
o List of IV fluids
o List of daily treatments
o List of diagnostic procedures ordered
4. Flow Sheets
 Enables nurses to record nursing data quickly and concisely and provides an easy-to-read record of the
client’s condition.
 GRAPHIC RECORD
o BT, PR, RR, BP, WT,etc.
 INTAKE AND OUTPUT RECORD
 MEDICATION ADMINISTRATION RECORD
 SKIN ASSESSMENT RECORD
5. Progress Notes
 Provide information about the progress a client is making toward achieving desired outcomes.
 Includes about client problems and nsg interventions.
6. Nursing Discharge/Referral Summaries
 Completed when the client is being discharged and transferred to another institution or to a home
setting.
 If the discharge plan is given directly to the client and family, it is imperative that instructions be written
in terms that can be readily understood.
 If a client is transferred within a facility or from a long-term facility to a hospital, a report needs to
accompany the client to ensure continuity of care.

LONG-TERM CARE DOCUMENTATION

 Skilled care = require more extensive nursing care and specialized nursing skills
 Intermediate care = needed for clients who usually have chronic illnesses and may only need assistance with
activities of daily living

GENERAL GUIDELINES FOR RECORDING

1. Date and Time

 Essential not only for legal reasons but also for client’s safety.
2. Timing
 Adjust the frequency as a client’s condition indicates.
 No recording should be done BEFORE providing nursing care.
3. Legibility
 Writing should be legible and easy to read
 4. Permanence
 All entries should be made in dark ink so that the record is permanent.
5. Accepted Terminology
 Use only commonly accepted abbreviations, symbols, and terms that are specified by the agency.
6. Correct Spelling
 Essential for accuracy in recording.
 If unsure, look it up into the dictionary or references.
7. Signature
 Trodot
 Signed by the nurse making it.
8. Accuracy
 Client’s name and identifying information should be stamped or written on each page of the clinical
record.
 Notations on records must be accurate and correct.
o Consists of facts or observations rather than opinions or interpretations.
 When mistake is made, draw a line through the text and write the words “mistaken entry” above or next
to the original entry with your initials ro name.
9. Sequence
 Document events in order.
10. Appropriateness
 Record only information that pertains to the client’s health problems and care.
11. Completeness
 Not all data that a nurse obtains about a client can be recorded. However, the information that is
recorded needs to be complete and helpful to the client and health care professionals.
 Nurse’s notes need to reflect the nursing process.
12. Conciseness
 Recordings should be brief as well as complete to save time in communication.
 Client’s name and the word client is omitted.
13. Legal Prudence
 Accurate, complete documentation should give legal protection to the nurse, the client’s other
caregivers, the health care facility and the client.
 Admissible in court as legal document.

REPORTING

 Purpose of reporting is to communicate specific information to a person or group of people.

 Report, oral or written, should be:
o Concise
o Including pertinent information but no extraneous detail
 Can also include the sharing of information or ideas with colleagues and other health professionals/
1. Change-of-Shift Reports
 Given to all nurses on the next shift.
 Purpose is to provide continuity of care for clients by providing the new caregivers a quick summary of
clients needs and details of care to be given.
 May be written or rally either in a face-to-face exchange or audiotape recording.
 Reports are sometimes given at the bedside and clients as well as nurses may participate in the
exchange of information.
2. Telephone Reports
 Health care professionals frequently report about a client by telephone
  Nurse receiving a telephone report should document the date and time, the name of the person giving
the information, and the subject of the information received, and sign the notation.
 Telephone reports usually include the client’s name and medical diagnosis, changes in nursing
assessment, v/s related to baseline vital signs, significant laboratory data and related nsg intervention.
3. Telephone orders
 Physicians often order a therapy for a client by telephone.
 Write the complete order down and read it back to the primary care provider to ensure accuracy.
 Question the primary care provider if the order is ambiguous, unusual, or contraindicated to the pt.
 Transcribed the order onto the physician’s order sheet, indicating that it is a VERBAL ORDER (VO) or
telephone order (TO).
 The order must be countersigned by the physician within a time period described by agency policy.
4. Care Plan Conference
 Meeting of a group of nurses to discuss possible solutions to certain problems of a client, such as
inability to cope with an event or lack of progress toward goal attainment.
 Allow each nurse an opportunity to offer an opinion about possible solutions to the problem.
 Most effective when there is a climate of respect – that is nonjudgmental acceptance of others even
though their values, opinions, and beliefs, may seem different.
5. Nursing Rounds
 Procedures in w/c two or more nurses visit selected clients at each client’s bedside to:
o Obtain information that will help plan nursing care
o Provide clients the opportunity to discuss their care
o Evaluate the nursing care the client has received.
 The nurse assigned to the client provides a brief summary of the client’s nursing needs and the
interventions being implemented
 Offer advantages to both clients and nurses
o Clients: can participate in the discussion
o Nurses: can see the client and the equipment being used.
 Nurses need to use terms that the client can understand (layman’s terms)