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Documentation

Patient documentation is a critical written record detailing medications, treatments, education, and patient activities. It serves multiple purposes including accreditation, reimbursement, legal protection, and communication within healthcare teams. To maintain confidentiality, accuracy, and thoroughness is essential. Each entry must be factual, timely, and signed. Common errors include not recording verbal orders and charting in advance. Different documentation formats exist, such as SOAP and PIE. Effective documentation supports continuity of care and satisfies legal standards while ensuring patient safety.

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Documentation

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  1. Documentation

  2. What Is It? • Written record of everything done for a patient • Medications • Treatments • Activities • Education • supplies

  3. Purpose • Accreditation • To prove meeting prescribed standards • Reimbursement • To show what was used • Legal • Shows condition of patient before, during and after treatment • Communication • Within the health team

  4. Special Considerations • Confidentiality • Only for those with “need to know” • Must be accurate and thorough • Must be legible

  5. Characteristics • Factual • Describe findings, not what “seems” or “appears” • Use exact patient statements, put in “ ---” • Accurate • Precise measurements • No unnecessary words • Only pertinent details • Correct spelling

  6. More Characteristics • EACH ENTRY MUST BE: • Timed • At the time of activity ** • Dated • Signed • By the person recording • **exceptions: • after shift • Team effort

  7. Signatures • First name or initial • Full last name • Title (ADNS) • At least once per page • Then may use initials

  8. Still more characteristics • Completeness • Thoroughly describe events using details of • Quality • Quantity • Duration • Measurements • Rating scales

  9. yet more characteristics • Current • Up to the minute • Don’t ‘wait til later’ • Organized • Use a logical method • Make & review notes before writing in record

  10. Legalities • NEVER: • Erase • use white-out • scratch or scribble out • ALWAYS • Omit critical commentary • Completely record FACTS • Record clarification efforts • Write legibly, use black ink • Correct errors promptly

  11. IMPORTANT • If it isn’t written, it wasn’t done

  12. Malpractice Issues • Incorrect time of when events occurred • Not recording verbal orders • Not getting verbal orders signed • Charting actions in advance • Documenting incorrect data

  13. Types of Records • Facility designates which format of documentation • SOAP • Subj, obj, assess, plan • PIE • Plan, implement, evaluate • DAR • Data, actions, responses

  14. Discharge Planning • Begins at time of admission • Must educate the patient • Throughout hospital stay • Diet, meds, treatments, rehab, community resources • Continuity between health teams

  15. End of Shift Reports • Report facts • Obj & subj data • Info about family, prn • Responses to care or treatments • Occurrences

  16. Telephone or Verbal Orders • Listen carefully • Write down on notepad • Ask questions if necessary • Read back to physician • Document on order page • Sign after order: • T.O. Dr.Fry/N. Nurse, RN • V.O. Dr. Oar/N. Nurse, RN

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