• a chart is alegal document
• a chart is the client's health care record
• a chart is the storage place of all the documentation concerning the status of the client and the care provided
• used by all members of the health care team

• record or admission 
• consent for treatment
• graphics sheets/flowsheets
• nursing history/database
• nurse's note's /flowsheats
• medication records 
• records of the different therapies
• physician history and physical form
• physician's orders
• physician's progress notes
• reports from lab
• orther testing results
• records of surgery and other procedures 
• discharge planning/utilization review records 
• social services

• the chart is a legal document and is admissible in court as evidence
• maintains legal evidence of care provided to the client
• proof of compliance with the state's Nurse Practice Act
• healthcare providers have a duty to maintain an accurate and complete recording of all relevant events

• reveals the client's health status
• documents status from admission to discharge

• between services
• prevents overlapping of activities 
• facilities coordination & continuity of care

• helps anticipate needs & is a valuable source of information for research

• used to monitor care & for cost effectiveness
• documents compliance with accreditation and licensure mandates

• documents extent to which agency should be reimbursed for services

• what is written in the client's record or what you observe in the client's record is confidential
• you may not legally or thically reveal the contents of a client's chart to anyone outside of the healthcare situation 
• will discuss more in legal lecture

• documents for specific events/information
• lab report
• incident report

• the passing of vital information 
• between staff 
• between the discipline
• between shifts
• between agencies

• anything written or printed that is relied on as a record of proof for authorized persons
• a legal account of how the nurse fulfills her/his professional responsibilities 
• the actual process of putting down into words what you are doing and the client's response
• an estimated 15-20% of nursing work is spent documenting client care and information 

• to provide for continuity of care
• to provide proof of interventions
• to add to the database of information on the client
• to provide a record of what occurred for those who need to know about the situation (provides detailed information)

• proof of provision of competent nursing care
• provides evidence of your involvement with clients
• failure to document nursing actions could be interpreted as failure to provide care
• should be detailed enough to demonstrate that you have fulfilled your professional and legal duty of care
• often the first impression a court of law has of you is from your nursing notes
• if your notes are unprofessional, then the assumption will be made that you are as well

• professional standards of practice
• nurse practice acts
• accreditation agencies
• regulartory agencies
• reimbursement agencies
• institutional nursing policies 
• nursing service department of the health care agency selects the format used to document care

• POMR (problem oriented medical record
• SOAP
• PIE
• traditional or narratice nurses' notes
• focus charting
• CBE (charting by exception) charting
• flowsheets and databases

• focuses on one diagnosis
• it is client-centered
• follows the nursing process
• major components:
• data base - usually completed by nurse
• problem list - listed in chronological order, not in order of priority
• initial care plan
• progess notes
• discharge summary

• encourages a problem solving apporach (nursing process)
• all health team members may record on the same form
• promotes interdisciplinary communication 
• reduces redundancy
• easy to follow the course of a specific problem
• enhances consistency of documentation 

• essential information can be left out
• more difficult to do than narrative notes (more time consuming)
• recording one time actions can be a problem
• not well suited for settings with rapid turnover (such as ER and outpatient surgery)
• requires a significant amount of training to use format

• SOAP(IER)
• S - subjective date (captures client point of view)
• O - objective data (assessments & observation)
• A - assessment of the data (may be a nursing dx, an impression, or a condition change)
• P - plan of care (specific directions for care, etc.)
• I - interventions (specific interventions carried out)
• E - evaluation (client's response & progress to goals)
• R - revision (any changes from the original plan of care) 
• Labeled APIE format for documenting

• record simple data such as vital signs, neuro checks, etc (routine care)
• used to document nursing interventions and evaluation if the facility only uses SOAP notes without the IER

• these are not interdisciplinary notes
• developed in an effort to simplify and concisely organize nursing documentation 
• assessment findings are recorded in a daily flow sheet
• identified client problems are numbered and stated as nursing diagnoses 
• documentation is entered for each Nsg Dx during every shift 
• P - problem or nursing diagnoses
• I - interventions or actions taken
• E - evaluation of outcomes 
• differs from SOAP in that there is no assessment date in the note
• assessment data appears in the seperate flow sheets 

• emphasis is on nursing diagnoses and evaluation 
• well organized 
• easy tracking of problems
• less redundancy 

• significant training necessary 
• not conductive to multidisciplinary charting 

• also called traditional charting 
• a chronological written account of the clint's status, nursing interventions provided and the effectiveness of the interventions 

• client assessment
• nursing and medical interventions performed
• evaluation of the effectiveness of intervention
• specific measures carried out by the physician
• visits by the members of the health team 
• logs of events taking place during a specific time period (varies from unit to unit)
• organization is chronological 
• nurses record factual data - NOT CONCLUSIONS 

• easy to write (decreased time spent charting)
• increases willingness to make entries
• new info can be included without difficulty
• notes are in chronological order
• strongly conveys nursing interventions and client responses 

• may be disorganized and documentation may be fragmented 
• may be difficult to find information quickly
• may be no evidence of critical decision making by the nurse
• often lengthy 

• read other entries before you chart - then make additional comments on their findings, which demonstrates continuity of care
• record exact time events occured and include specific informaiton about the events
• if possible, document an event immediately after occurence (eliminates possibility of forgetting important information)

• notes are focused around: 
• an acute change or behavior
• specific medical conditions
• follow-up to a more complete assessment 
• encourages nurses to include any client concern, not just problem areas
• focus may be written as a nursing diagnosis 
• organization of note
• D - date (objective & subjective)
• A - actions (nursing interventions)
• R - response (evaluation of effectiveness of actions)

• can be adapted to any clinicla setting
• easy to find information on a specific problem
• documents client responses and outcomes
• easy to organize thoughts to document precisely

• requires use of many flow sheets and checklists
• may require in-depth training of staff

• charting by exception
• standards of practice are integrated into documentation forms
• nurse only documents significant findings or exeptions to the pre-defined norms

• alerts nurses to changes or problems
• easy to track changes
• decreases time spent charting - no entries in narrative form unless something out of the ordinary occurs 
• the assumption is that all standards are met unless otherwise documented 

• major time commitment to establish clear guidelines and standards of care
• these must be understood by all nursing staff
• unexpected events or isolated occurences may not be fully documentd
• many nurses are uncomfortable with only charting exceptions to the norm
• "not charted = didn't happen" belief

• keeps everything together
• more legible
• access to data at different locations 
• ease of access
• multidisciplinary access 
• reduces redundant charting 
• alerts health care team to critical information 

• changing formats
• hardware/software/power problems
• can be difficult to retrieve the data 
• expensive 

• increases access to information by almost everyone 
• information can be accidntally deleted
• need to protect printouts of computerized 

• DO NOT share your passwork with anyone (it is your legal electronic signature)
• log off when leaving a terminal - even if only for a few minutes
• never display information on a monitor where someone else can see it
• never print information and leave it unattended
• follow agency policy for correcting documentation errors

• we are seeing more of this with the use of computers and hand-held devices (PDA's)
• documentation takes place as care occurs
• studies are being done to see if this has any effect on client satisfaction r/t health care delivery

• a flowsheet generally trends the activity for a day or for a particular treatment or day
• diabetic flowsheet
• restraint flowsheet
• post procedure checklist
• database
• admission or baseline assessment 
• history and physical of the patient 
• discharge summary

• a seperate portable form kept at the nurse's station - easily accessible
• contains information needed for daily client care
• should reflect the client's most current activities
• may be kep separately from the rest of the charting
• patient care kardex
• many different segments (diet, wt, activity, therapies, some treatments, etc.)
• medication kardex
• a.k.a. med sheet, medication administration record (MAR), med record
• treatment kardex

• multidisciplinary care plans for the problems, key interventions, and expected outcomes of the client with a specific condition
• all caregivers may use one critical pathway as a monitoring and documentation tool
• a checklist format can be used instead of a narrative format - chart only variances (both positive and negative) from the expected outcomes. 
• involves the entire health team
• identifies expected outcomes for each day of care
• may use different symbols in each facility

• linked to NANDA nursing diagnosis labesl
• interventions are suggested for each nursing diagnosis
• nurses must select appropriate interventions based on judgement and knowledge of the client 
• then, must individualize for specific client 

• describes client outcomes that respond to nursing interventions
• broadly stated - must be made more specific for each client
• each outcome includes a 5-point scale to rate the client's status

• pertinent information is shared between nurses at the change of a shift
• can be done orally or written or a combination of both
• report:
• client's name, age, room number, diagnosis, physician(s)
• diet, activity status
• any scheduled tests or procedures and specific instructions (ie, NPO)
• IV access and fluids
• pain level and management
• any abnormal findings in the physical/head-to-toe assessment
• any changes in client status during the shift
• any orders that need to be continued onto the next shift

• follow agency policy
• know when, where, and what to chart
• chart promptly 
• use approved abbreviations for the facility
• be brief, concise, clear, and to the point
• observations, not interpretations
• be accurate
• write legibly 
• watch your spelling and grammar
• documents as soon as possible after providing nursing care - helps avoid errors
• document contact with colleagues such as physicians, supervisors, or other nurses
• thoroughly document any client refusal treatment
• document any client teaching done

• record all entries legibly and in ink
• some places use different colors for different reasons or shifts
• begin each entry with the date and time
• example: 2/12/14 1200
• chart chronologically
• leave no blank spaces, end with a line over, your first initial, last name, and title
• -------------------------------------E. Goen, SN ISU

• record factual data - try to avoid words that are open to interpretation 
• - appears, seems, normal, good, poor, etc...
• example
• incorrect: chest looks good. incision looks good
• correct: chest incision cleansed with betadine. incision approximated with signs of infection. staples intact. left open to air as instructed by physician
• DO NOT write clinical or retaliatory comments about the client or care provided by other staff

correting an error

• correct all errors promptly
• do NOT erase, white-out, or scratch out an entry in a client's record
• DRAW A SINGLE LINE THROUGH A MISTAKE AND NOTE IT AS AN ERROR or MISTAKEN ENTRY WITH YOUR INITIALS
• late entry - follow your agency policy for a late entry, but do document the information