Education 

Legal 

documentation

Research

Financial billing Communication Monitoring

Purpose of records

• Legally and ethically obligated to keep patient 

information confidential.

• Protect records from unauthorized readers

• Health Insurance Portability and Accountability 

Act (HIPAA) governs all areas of information 

management

Patient Rights regarding 

Health Information

• Patient education on privacy protections

• Ensuring patients’ access to their medical records

• Receiving patient consent before information is 

released

• Providing recourse if privacy protections are 

violated

Systematic  

Continuous

Accessible

Recorded

American Nurses Association

– Confidential permanent legal documen

Reports

– A professional caregiver providing formal advice to 

another caregiver

 Arrangement for services by another care provider

Patient Chart  or record

• Identification and demographic data

• Informed consent for treatment and procedures

• Medical History/Medical diagnoses

• Therapeutic orders

• Medical and health discipline’s progress notes

• Report of physical examination

• Report of diagnostic tests/labs

• Admission nursing history

• Nursing diagnoses or problems  & plan

• Client education

• Summary of operative procedures 

• Discharge plan or summar

 significant 

information about the patient’s health status, 

what needs to be done, wound 

care/condition, provides baseline for 

oncoming nurses. Objective, current, concise

– Oral

– Audio tape

– Written

– “Walking rounds

Telephone reports

• Provide clear, concise, accurate information

• Document: when, who made call, who was 

called, to whom info was given, what info was 

given, what info was received

Telephone or verbal orders

• TO or VO

• Person receiving order must read it back to 

the caller

 report given when patient is 

transferring to another unit 

Incidence or occurrence report

• Incident not consistent with routine care & 

safety issues

• Record what actually happened

• Do not record in medical record that incident 

report was filled out

• Used in quality improvement programs to 

monitor trends

• Accurate – best defense for legal claims associated 

with nursing care

• Clearly indicate individualized goal directed nursing 

care

• Exactly what happened to patient

Factual

• Descriptive, objective data about what you 

see, hear, feel, or smell

• Result of direct observation and measurement

– NO seems, appears, apparently

• Subjective data – document patient’s exact 

words in quotation mark

• Exact measurements

• Clear and easy to understand, no irrelevant 

data

• Only approved abbreviations 

• Correct spelling

• Signed with date, time, name, title; if initials 

used must identify with full name on same 

page

• Appropriate and essential information

• Subjective data

• Patient behavior

• Objective data

• Nursing interventions: treatments, medication 

administration, patient teaching, discharge plans

• Example text p. 389

• Timely entries

• Record at time of occurrence**

• Vital signs

• Treatments and medications

• Preparation for diagnostic tests

• Change in patient status, who notified and treatment**

• Admission, transfer, discharge, death of patient

• Patient’s response to treatment or intervention

• Majority of hospitals use military time

• Table 26-3 text p. 392

• Logical order

• Problem, your assessment, intervention, 

patient response.

• Using the nursing process to record will 

ensure logic and order 

narrative

• The traditional method***

• Paragraph form, long, time consuming

• Does not have a specific structure

• Information can be organized in any logical 

manner

• Note must still reflect progress toward goals

• Box 26 5/13/2011

-3 text 392

Problem Oriented Medical Record

POMR

• Database

• Problem list

• Nursing care plan

• Progress notES

SOAP: Spain RehaB

– Subjective, objective, assessment, plaN

– Subjective, objective, assessment, plan, intervention, 

evaluatioN

– Data, action, response [plan]

– Occurs for exception to plan or outcome not achieve

Admission nursing history form

Flow sheets and graphic records

Client care summary or Kardex

Acuity records

Standardized care plans Discharge summary form

Common Record Keeping Forms

Nursing Informatics

• Integrates nursing science, computer science, and information science. 

• Facilitates integration of data, information, and knowledge to support patients, nurses, and other provider supports up-todate evidence based practice

• Effective nursing information systems meets two goals:

1. Supports nurses function and work.

2. Supports and enhances nursing practic

Nursing process design

• Organizes documentation within well-established 

formats such as admission and post operative 

assessments, problem lists, care plans, discharge 

plans, intervention plans or notes

Protocol or critical pathway

• Multidisciplinary approach to managing data

• Health care providers use protocol system to 

document care given