Get Ready for the NCLEX Examination!

Key Points

•Documentation is part of the implementation phase of the nursing process and is used in evaluation.
•Only approved abbreviations and medical terms should be used when charting in a patient’s record. Knowledge of the common abbreviations and terms is required.
•The five purposes for patient records are: (1) a means of communication to facilitate continuity of care; (2) a permanent record for accountability purposes (audits, accreditation, and cost reimbursement); (3) a legal record; (4) usage in teaching; and (5) usage for research and data collection.
•Many facilities have an electronic health record (EHR) or electronic medical record (EMR) system in place to facilitate documentation and coordination of patient care.
•SBAR (Situation, Background, Assessment, and Recommendation) aids in communication during “hand-off” or “handover” interactions with other health care personnel.
•Two common types of medical records or charts are the traditional (block) chart and the problem-oriented medical record (POMR).
•The POMR uses a master patient problem list as an index to the chart. These listed problems are usually medical diagnoses.
•SOAPIER is one format for charting in the POMR. The letters stand for subjective (S), objective (O), assessment (A), plan (P), implementation (I), evaluation (E), and revision (R).
•Two other common formats for charting nursing notes are narrative and focus. Focus charting includes data (D), action (A), response and evaluation (R), and education and patient teaching (E).
•Charting must be legible (with handwritten documentation), clear, concise, accurate, and complete. These guidelines serve as a national standard for licensed nurses.
•The specific institution or unit often has specific forms and charting formats; in addition, the general guidelines and rules for charting should be followed.
•Medical records are legal documents. The health care provider or institution owns the original record.
•Lawyers, courts, and patients are able to gain access to the record by following specified access procedures.
•The contents of a health record are confidential information protected by the law and the Patient Care Partnership.
•The nursing Kardex or Rand is a card-filing system used in some facilities by nurses to condense all the orders and other care information needed quickly for each patient. It is updated frequently.
•Computerized information systems provide information about a patient in an organized and easily accessible fashion.
•Clinical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type.
•Many agencies use military time. This system uses four-digit numbers to indicate morning, afternoon, and evening times.
•A 24-hour record-keeping system helps eliminate unnecessary record-keeping forms.
•The acuity level determined by analyzing what nursing care is necessary allows patients to be rated in comparison with one another. Staffing patterns can then be determined by examining the acuity levels for the patients on a particular nursing unit.
•Fax machines are used to send written documents over telephone lines to quickly transmit data between hospitals and other facilities, such as health care provider offices.