Documentation

 Core Standards for Documentation

 Professional Practice
 Forms
 Content = Assessment
 Timing

 Date, Time, Signature & Designation

 Objective & Subjective Data

 Confidentiality
Professional Practice
 Nurses document for
individuals, families or groups
of clients.
 A nurse’s documentation
provides a clear picture of the
needs and goals of the client,
the actions of the nurse and
outcomes.
Documentation: “Voice of Nursing”
 Structured and focused communication in
regards to documentation between
caregivers promotes better client care
decisions.
 Research indicates that poor recordings is
reflected in nursing interventions and
client outcomes.
 As professionals, nurses bear the
responsibility of what they have done. The
Supreme Court of Canada has ruled that
nursing documentation is admissible
evidence.
Documentation Forms
 Effective documentation forms provide
a framework and guide documentation.
 To remain effective, forms often require
regular review and revision.
 Types of Forms:
 Worksheets and Kardexes

 Care Plans

 Flow sheets and Checklists

 Monitoring Strips
 Worksheets

 Nurses use worksheets to

organize the care they provide,
and to manage time and multiple
priorities for up to 4 or 5 clients.
 Example: George Brown College
“Daily Clinical Worksheet”
Nursing Worksheet Example
 Kardexes

 Kardexes are a communication

tool used to convey the client’s
current orders as well as
upcoming tests or surgery, diet,
hygiene assistance, ambulation
assistive devices, nutrition, code
status, etc…
Kardex Example
 Worksheets and Kardexes
 The information kardexes and
worksheets contain may be erasable as
long as the permanent health record
reflects the nursing assessment, the
care provided and the outcome.
 A nurse meets the standards by:
 updating the Kardex information regularly.
 ensuring that temporary worksheets are

shredded when no longer in use.

Flow Sheets and Checklists
 Flow Sheets document routine care and
frequently recorded information.
 Examples:
 Activities of Daily Living (ADLs)

 Vital Signs

 Intake and Output

 When using initials on a flow sheet, a master

list matching the initials to the caregiver is
needed.
Treatment Sheet - ADLs

The nurse’s initials

should be placed at the
bottom of the column as
this is a flow sheet for
24 hours.
 Assessment

 Documenting the assessment of a client

includes recording:
 Subjective Data = “Says” and Symptoms

 Objective Data = See and Signs

 Data can be also from:

 Third-party
 Example: Family member

 Collaboration with Care Providers

 Example: CCAC Nurse
What the nurse observes by using
senses…

Vision

Hearing

Smell Touch
Subjective Data = Says “Verbally”

 What the client says.

 Referred to as symptoms that are
apparent only to the person
affected and can be described or
verified by that person.
 Objective Data = Observation

 What the nurse observes.

 Referred to as signs, detectable by
an observer or can be tested against
an accepted standard (seen, heard,
felt or smelled).
 Subjective and Objective Data
Subjective Objective
 “I feel weak all  Blood pressure = 90/50
over when I exert  Apical pulse = 104 BPM
myself.”  Skin pale and diaphoretic
 “I am feeling short  Chest assessment reveals,
of breath.” diminished breath sounds to
RLL.
 Client states he has  Vomited 100 mL green-
a cramping pain in his tinged fluid
abdomen. States, “I  Active bowel sounds
feel sick to my auscultated X 4 quadrants
stomach.”
Evan age 84 complains of breathlessness and
a fuzzy head. He admits to worrying about
everything and isn’t sure what the matter is.
His pulse is 85, BP 160/90. His skin is dry,
pink and warm to touch. He is frowning
when you enter the room.

Subjective Objective
 Abbreviations and Symbols
 Abbreviations and symbols can be an effective and
efficient form of documentation if their meaning is
well understood by the health care providers and
others who may read the health record. However,
abbreviations and symbols that are obscure,
obsolete, poorly defined or have multiple meanings
can lead to confusion, errors and wasted time.
 Examples of error prone abbreviations and symbols:
 DC, D/C, dc = Discharge and discontinue
 Rationale: Mistaken for each other
 Dysphagia = Difficulty digesting/
gastrointestinal issues
 Dysphasia = Difficulty speaking
 IU = International Units
 Rationale: Can be mistaken for IV
(intravenous) or 10 (ten)
 @ and & =“at” and “and”
Example: Abbreviations and Symbols
 09/08/09 at 1210 hours:
 Dr. Smith in and removed drsg to assess wound
from # ® tibia. New drsg orders received to  drsg
’s from BID to once daily and prn. New drsg
applied to ® lower leg for scant amt of sero-
sanguinous drainage. Incision well approximated, ø
redness or swelling. Cleansed c N/S and dry 4X4
gauze drsg applied & fixed c transpore tape. ® leg
 X 2 pillows. Client stated to writer, “This injury is
going to ruin the ski season for me, oh well, I
guess I should be happy the rain got rid of all the
snow so I know I can’t ski for sure”. Client resting
in bed and ø voiced concerns at this given time.
--------------------------------------------------A. Lalonde
RN
 Information documented during or
immediately after care is provided
or an event has occurred is
considered more reliable than
information recorded later, based
on memory.
 Chronological entries present a
clear picture of events.
Timing: Forgotten or Late Entries,
Errors and Omissions
 For documentation to be reliable, it
must clearly state when care was
provided or an event occurred and
when the documentation of the care/
event occurred.
 Regardless of how late the entry, the
information documented must be
accurate and complete.
 Timing Example
Timing
Past Tense
Why?
The event
has already
occurred

Late Entry
Date, Time, Signature and
Designation
Date = Month/Date/Year
 Date and Time:
 Documenting in the
health record the date
and time that care
was provided and was
recorded supports the
primary purpose of
documentation, which
is communication.
09/10/09 @ 0400 Hours
 Date and Time
Regular Time Military Hours Regular Time Military Hours
 12:00 AM  2400 Hours  12:00 PM  1200 Hours
 1:00 AM  0100 Hours  1:00 PM  1300 Hours
 2:00 AM  0200 Hours  2:00 PM  1400 Hours
 3:00 AM  0300 Hours  3:00 PM  1500 Hours
 4:00 AM  0400 Hours  4:00 PM  1600 Hours
 5:00 AM  0500 Hours  5:00 PM  1700 Hours
 6:00 AM  0600 Hours  6:00 PM  1800 Hours
 7:00 AM  0700 Hours  7:00 PM  1900 Hours
 8:00 AM  0800 Hours  8:00 PM  2000 Hours
 9:00 AM  0900 Hours  9:00 PM  2100 Hours
 10:00 AM  1000 Hours  10:00 PM  2200 Hours
 11:00 AM  1100 Hours  11:00 PM  2300 Hours

Note: 12:00 AM = 2400 Hours but 12:01 AM to 12:59 AM = 0001 to 0059 HOURS
Date, Time, Signature and
Professional Designation
 Signature and Professional Designation:
 When nurses use their professional designations
in documentation, it indicates that an accountable
regulated health professional has provided the
care.
 Use of signature and designation of health care
providers promotes communication and supports
accountability. When using initials in
documentation, a master list that identifies the
caregiver’s full name, designation, full signature
and initials should be maintained to clarify
accountability.
 Nurses use the designations RN for Registered
Nurse and RPN for Registered Practical Nurse.
GBC Signature and Designation

 George Brown College Semester II

Practical Nursing Student will use
the following as their designation:

J. Channel GBC SPN2

 Documentation Methods
 The documentation method used by a practice
setting should reflect client care needs and the
context of practice. Some facilities/agencies may
combine elements of different documentation
methods and formats to document care effectively.
Regardless of the method of documentation used,
the health record must present a clear picture of the
nurse’s assessment, actions and outcomes.
 Common documentation methods include:
 Narrative Documentation
 DAR/E = Focus Charting
 Computerized Documentation (Nursing Information
System)
 SOAPIER
 Charting by Exception
 Critical Path/Variance Analysis (Care Mapping)
Computerized Documentation
Computerized Documentation
 Nurses have been using computerized
systems for supplies, equipment, stock
medications, and diagnostic testing for
some time. However, increasingly hospitals
are using computerized documentation
systems. Many systems give access to data
across the continuum (regardless of
setting) and capture useful information
from both individual clients and population
groups.
 Example: Meditech Information Technology
Objectives of Computer-Based Client
Care Record (CBCR)
 Improved uniformity, accuracy, and retrievability of data about
client care.
 Confidentiality of health care information ensured in the system.
 Access for authorized health care providers from any department.
 Ability to retrieve information selectively and choose various
formats for examining it.
 Assistance with clinical application, including analysis tools, risk
assessment, and clinical reminders.
 Support for data collection in a manner that adequately supports
health care providers' direct entry and stores information
according to a defined vocabulary.
 Easy access to client data, fast retrieval, and versatile data display
that facilitates improved health care delivery.
 Availability of a lifelong record of health-related events
incorporating records from various settings and time periods.
Nursing Information System:
The “Pros”
 Anecdotal reports and descriptive studies suggest
that nursing information systems do offer
important advantages to nurses in practice.
 Increased time to spend with clients
 Better access to information
 Enhanced quality of documentation
 Reduced numbers of errors of omission
 Reduced hospital costs
 Increased nurse job satisfaction
 Enhanced compliance with accreditation
standards
 Development of a common clinical database
Nursing Information System:
 Can threaten a client’s right to confidentiality if
appropriate security measures are not taken, such as:
 Installation of firewalls
 Antivirus software
 Spy-ware-detection software
 Authentic access codes and passwords
 Physical placement of computers or file servers in
restricted areas
 Can be expensive to implement and maintain.
 Mobile wireless devices such as notebooks, tablet
personal computers or personal digital assitants can be
misplaced or lost, which allows them to be accessed by
unauthorized persons.
 Can take extra time if there are too many nurses trying to
chart on too few computer terminals.
Computerized Documentation Example 1
Computerized Documentation Example 2
SOAPIER Documentation
Problem-oriented approach to documentation in which
nurses document information in an organized fashion.
S Subjective: Verbalizations of the client.
O Objective: What the nurse observed.
A Assessment: Conclusion reached based on
subjective and objective data presented;
can be written in nursing diagnosis form.
P Plan: Planned course of interventions to
address the problem – what the nurse plans
I Intervention:
to do. Care actually provided by the
E nurse.
Evaluation: Reflects client response to
illness, medical treatment or interventions.
R Revision: Reflects change by the
evaluation; can be made in intervention
plans or target dates.
DATE TIME PROBLEM SOAPIER DOCUMENATION NOTE EXAMPLE

9/10/10 1415 #5 S: “My skin is itchy on my back and arms, and it

Generalized has been like this for a week”. ----------------------
Pruritis O: Skin clear, no rash or irritation noted. Marks
where client has scratched noted on left and right
forearms. Allergic to elastoplast bandaids but has
not been in contact during this hospitalization
stay. ----------------------------------
No previous history of pruritis.
A: Skin integrity impaired. ---------------------------
P: Instruct to not scratch skin.
Apply calamine lotion as necessary.
Cut nails to avoid scratches.
Assess further to determine whether
recurrence associated.
with specific drugs or foods.
Refer to physician and pharmacist for
assessment.
----------------------------------------
I: client instructed to not scratch skin. Applied
calamine lotion to back and arms at 1445 hours.
Assisted to cut fingernails. Notified physician and
pharmacist of issue. ---------------------------------
E: client states, “I’m still itchy. That lotion did not
help”. ----------------------------------------------
R: Remove calamine lotion and apply
hydrocortisone ointment as ordered. --------------
---------------------------------Signature and Status
Critical Pathways
 The standardized plan of care is
summarized into critical pathways for a
specific disease or condition.
 The critical pathways or CareMaps are
multidisciplinary care plans that include
client health concerns, key
interventions, and expected outcomes
within an established time frame.
Critical Pathways
Charting by Exception (CBE)
 Charting by exception (CBE) focuses on
documenting deviations from the established
norm or abnormal findings. This approach
reduces documentation time and highlights
trends or changes in the client's condition.
 CBE is a shorthand method for documenting
normal findings and routine care based on
clearly defined standards of practice and
predetermined criteria for nursing assessments
and interventions.
Charting by Exception (CBE)
Charting by Exception (CBE)
Narrative Documentation

 Nurses actions and client responses are

recorded in paragraph chronological
order and reflect care given within a
particular timeframe.
 Tends to be warranted and necessary
when the complexity of care requires
detailed, written explanations.
 May stand alone or be used in
combination with other documentation
tools (e.g., flow sheets).
Narrative Documentation
 When charting in narrative format use a systematic
manner of reporting your findings.
 LOC – Respiratory – Circulation – GI – GU – Pain (other)
 Assessment should focus on the following:
 Previous shift notes form nurses; physicians and other team
members.
 Intake (infusion rates and amount remaining in tube feeding, IV
and other infusions)
 Output (drainage amounts); indicate locations of tubes and
drains
 Dressings (degree and type of soiling, frequency of changes and
status of underlying skin/wound (REEDA)
 Treatments; Number of times performed, duration, and client
response
 Narrative Documentation Example
Date Time Disciplin Note Include
e Signature
09/10/10 0800 Nrsg  Received client alert, oriented x 3. Family at
bedside. Respirations even & non-laboured c
faint expiratory wheezes noted. Cough strong
c scant, thin, yellow secretions produced.
Chest tube in situ on ® chest wall c dressing
clean & dry. Atrium drainage collection set at
-20 cm H2O wall suction. Drainage serous &
moderate 30-40ml/hr. Pillow pressed to chest
by client to splint incision site during cough.
Skin warm & dry to touch c capillary refill < 3
seconds. Abdomen soft, non-tender c active
bowel sounds. Voiding s (without) difficulty.
No c/o pain at this present time.
--------------------------------------------------------
A. Lalonde RN
Focus Charting:
DARP versus DARE
 The focus charting mnemonic that is referred
to in Kozier et al., Chapter 23 is DARP. The
“P” stands for planning but being novice
clinical students, it is difficult to be able to
determine what plans will be most effective
for a client issue. Therefore, the focus for
COMM-1134 is going to be “E” (evaluation),
which is to assess your accountability to the
interventions that you implement.
Focus Charting = DAR/E
 In this system, the assessment of the client
and the care provided are organized under
data, action and response/evaluation.

 D = Data: Subjective and/or objective

information that supports or describes the
stated focus or describes nursing
observations at the time of a significant
event in treatment
 D: Patient complained nausea. Writer
noted patient was rubbing their abdomen.
Focus Charting = DAR/E
 A = Action: It is a nursing intervention and/
or implementing a physician’s order.
1. Intervention used to gather assessment data.
 A: Initial shift vital signs were taken.
2. Immediate nursing actions based on the nurse’s assessment of the
client’s condition.
 A: Gravol 50 mg IM was administered.
3. Evaluate a client response to an earlier intervention that was performed
based on an abnormal (subjective and/or objective finding).
 A: Writer reassessed pulse rate.
4. Future nursing action to evaluate a client’s condition because it may not
be possible to determine if intervention had an effect (i.e. , pain
medication).
 A: Writer will reassess patient in 45 minutes.
5. Obtaining and implementing medical orders from a physician or by the
physician themselves.
 A: Dr. Chan called in regards to patient’s decreasing O2 saturation.
Orders received to apply O2 at 3 LPM by nasal prongs. Dr. Chan will be in
to assess patient in 15 minutes.
Focus Charting = DAR/E
 R = Response: Description of client responses
to both medical and nursing interventions.
 R: The client reported the Gravol has helped
and they are no longer feeling nauseated.
 E = Evaluation: Is the concluding statement
that the intervention was effective or
ineffective based on the client’s response.
 E: The Gravol was effective in relieving the
client’s nausea.
 E: Tylenol E.S. were not effective in relieving
client’s headache.
Focus Charting = DAR/E
Focus Example
Current Behaviour or  Fear
Concern  Teaching Needs
Signs and/or Symptoms  Vomiting
 Itching
Acute Change in Status  Hemorrhage
 Sudden Elevation in B/
Significant Event in the P Blood Transfusion

Client’s Treatment  Return from Surgery
Nursing Diagnosis  Risk for Infection
 Impaired Physical
A Special Need Discharge Referral
Mobility

Focus Charting = DAR/E
 Components of DAR/E can be charted alone or
out of sequence:
 D = Data: Client c/o dull constant pain in the
right ankle and rates it 6/10. --------------------
 A = Action: Right ankle elevated on two
pillows. ---------------------------------------------
 R = Response: Client stated no relief. ----------
 A = Action: Administered two tablets of
Tylenol with Codeine. -----------------------------
 R = Relief noted from analgesic, now rates
pain a 2/10. ----------------------------------------
 E = Tylenol effective for c/o pain
----------------------------------------------------A.
Student GBC SPN2
 DAR/E Documentation Example
Date Tim Focus Note Include
e Signature
09/10/10 1015 Impaired  D: Bladder distended 2
Urinary
Elimination fingers above pubis. Has
not voided X 8 hours since
indwelling Foley catheter
was removed. -----------
 A: Assisted to washroom.
Water turned on at faucet.
Instructed client to press
over bladder region with
hands. ------
 R: Client voided a total of
525 ml of clear yellow
 DAR/E Documentation Example
Date Time Focus Note Include Signature

09/10/10 1600 Abnormal  D: Client stated that her period just started and she is
Vaginal passing clots. One peri pad noted to be saturated within 30
Bleeding minutes. client c/o feeling light-headed when ambulating.
----
 A: Vital signs obtained and PV loss assessed. ----------------
 D: BP: 94/52, P: 100, R: 20 and moderate amount of frank
bleeding with no clots noted. --------------------------------------
 A: Status reported to Dr. Medoffer and orders received. IV
started with a 20 G catheter, 1000 mL normal saline hung at
100 mL/h. Continue monitoring bleeding and vital signs.
client to be on BRPs. --------------------------------B. Student RPN
09/10/10 1645 Reassess  R: Vaginal bleeding has  to  pad q 90 minutes and
Vaginal client stated, “I am not feeling as light-headed as before”. ---
Bleeding  E: BRP and IV therapy were effective in  vaginal flow.
--------------------------------------------------------------------------
----
 A: Reported findings to T.L. J. Jones RN. -----B. Student RPN
Case Scenario Example
 According to her chart, Mrs. Johnson is seventy-six years old and
recovering from surgery to repair a left arm fracture four days ago.
Her past medical history indicates she has had a left sided CVA with
right hemiplegia. When you enter her room at 1:30 pm, you find her
watching television. You take her vital signs and find her
temperature to be 37.2º C, her pulse to be 76, her respiratory rate to
be 18, and her blood pressure to be 132/76. Dressing to the left arm
is dry and intact and colour, movement and sensation is within normal
limits. You also complete a pain assessment, which the patient denies
any pain and rates a 0/10. Her only complaint is that she has a dry
mouth. You provide mouth care. She reports that the mouth care did
not relieve her dry mouth and requires ice chips. You provide ice
chips and she states, “Thank you, the ice chips have really helped”.
 Note: Record your entry 10 minutes after the interaction has
occurred.
 Narrative Documentation Example
Date Time Disciplin Note Include
e Signature
09/10/10 1340 Nrsg
Upon entering room @ 1330
hours, pt. was watching TV. V/S
obtained & revealed: T = 37.2º
C; P = 76; R = 18 and BP =
132/76. Drsg to arm dry &
intact. CMS WNL. Pain
assessment completed & pt.
denied pain; rated 0/10 on pain
scale of 0 to 10. Pt. did c/o dry
mouth. Provided mouth care
little effect. Pt. requested ice
 DAR/E Documentation Example
Date Time Focus Note Include Signature
09/10/10 1340 Pain D: D: Upon entering room @ 1330 hours, pt. was
watching TV. -----------------------------------------------
A: V/S taken. ----------------------------------------------
D: T = 37.2º C; P = 76; R = 18 and BP = 132/76.
Drsg to arm dry & intact. CMS WNL. ------------------
A: Pain assessment performed. ------------------------
Dry Mouth D: Pt. denied pain; rated 0 on pain scale of 0 to 10.
D: Pt. c/o dry mouth. ------------------------------------
A: Provided mouth care. ---------------------------------
R: Pt. reported mouth care did not help &
requested ice chips. --------------------------------------
E: Mouth care ineffective for c/o dry mouth. ---------
A: Ice chips administered. ------------------------------
R: Pt. stated, “Thank you, the ice chips have really
helped”. -----------------------------------------------------
E: Ice chips effective for relieving c/o dry mouth. ---