DEFINITION

Nursing
documentation is
a
vital
component of safe, ethical and
effective nursing practice, regardless of
the context of practice or whether
the documentation is
paper-based
or
electronic.

PURPOSES OF DOCUMENTATION
Evidence of the care provided.
Evidence of quality care.
Evidence of necessary and ordered care.
Impact on regulatory requirements,
reimbursement and litigation;
List 3 charting tips to assure
documentation is accurate and correct.
State 3 legal aspects of nursing
documentation.

State 3 legal aspects of nursing documentation.

Explain the importance of using proper
spelling and grammar.
Professional responsibility
Accountability
Communication
Education
Research
Satisfaction of Legal and Practice standards
Reimbursement

Why is clinical documentation

important?

Documentation is critical for patient care

Serves as a legal document
Quality Reviews
Validates the patient care provided
Good documented medical records reduce
the re-work of claims processing
Compliance with CMS, Tricare and other
payers regulations and guidelines
Impacts coding, billing and reimbursement

Impact of clinical
documentation
Patient

Facility

Quality of care
provided
Continuity of care
Non-payment by
Insurance for
illegible condition or
treatment

Coding and Billing

Supporting
documentation for
treatment and
services rendered
Appropriate
reimbursement

Principles of Documentation
Complete and legible
All entries should be dated and
authenticated by physician/provider

Documentation of each patient encounter

Date & Reason for the encounter
Appropriate H&P and prior diagnostic test
results
Review of lab, x-ray data and other ancillary
services
Assessment and Plan of Care (discharge plan)

Codes reported should reflect the

documentation

Principles of Documentation
Past & present diagnoses
should be accessible to physician (treating
or
consulting)
Reason for and results of x-ray, labs should
be documented
Relevant health risk factors should be
identified
Documentation should support
Diagnosis and describe the patients treatment

Principles of Documentation
Patients progress notes should include

Change in diagnosis
Response to treatment
Change in treatment
Patient non-compliance

Discharge Plan/Plan of Care should

include

Treatments and medications

Frequency of medication & dosage
Any Referrals
Discharge instructions for follow-up

ELEM ENTS OF EFFECTIVE

CHARTING
Comple
te

Date and time

Legible
Accurat
e
Order as given
by the physician
Clinical
Documentat
Signature beginning
with t.o.
ion in the
(telephone
Patient order)
Medical
Centere
Timely
Record
Physicians
name
d
should be
Nurses signature
Clear countersign
Concise
Physician must

PROTECT Y OUR
PRACTICE

Accurate nursing
documentation can
prevent a lawsuit!
Documentation must be:
TIMELY, ACCURATE&
COMPLETE

Sign Your Note and Include Your

Credentials
Record your full name, credentials and
job
title in the appropriate section on forms.
Your signature must be in cursive.
Take the time to sign your name legibly

Why is clinical Documentation Important?

Improved quality of care
Correct, complete, accurate documentation impacts
patients, physicians and MTFs
All clinicians are responsible for documenting the
treatment and outcomes of the patient
Documentation is used for clinical research and
education
Supports diagnoses and procedures that were billed
Impacts reimbursement
Compliance with CMS regulations

Documenting a Telephone Order

from a Physician
Indicate date/time order was received
Document order as stated by physician
Read the written order back to the physician to verify
accuracy
Document under the order RBO (read back order) and
the recorders initials
Sign order: v.o. Dr. Jones / Kay Smith RN
Place a sign here sticker next to order
Flag the record green for a regular order and red for a
STAT order for the secretary

Nurses Notes
Used to document:
Clients condition, problems, and complaints.
Interventions.
Clients response to interventions.
Achievement of outcomes.

Example:

Pain: 11:00 a.m., Resident complains of left

knee pain 7/10, dull and throbbing, facial
grimacing and moaning with movement.
Treatment: 11:10 a.m. Tylenol #3, i tab p.o.
per order given and pillow placed between
residents knees.
Response: 12:00 resident reports left knee
pain is improved, dull ache 2/1

Chronology: Date and Time

Date and time.
Year
a.m. or p.m.
Do not chart in blocks of time such as 0700 to
1500.
Late entry:
"late entry for _______" to designate the time
of the events or observations documented.

Chart important information from visits by

physicians or other health care team members
such as dietician, social worker, hospice, etc.
Chart as soon as possible after giving care.
Chart the resident's subjective data including
what the resident perceives and the way they
express it. Use direct quotes when possible
using quotation marks

If you don't give a medication as ordered,

circle the time and document the reason for
the omission.
Include important information remembered
later as a "late entry", noting the date and
time of the late entry.
If information on a pre-printed form does not
apply to your client, write NA for "not
applicable" rather than leaving it blank.

Incident Reports

The documentation of any unusual

occurrence or accident in the delivery
of client care, such as falls or
medication errors.

Discharge Summary
Highlights clients illness and course of care.
Includes:
Clients status at admission and
discharge.
Brief summary of clients care.
Intervention and education outcomes.
Resolved problems and continuing care
needs.
Client instructions regarding
medications, diet, food-drug interactions,