Documentation. 4. If you forgot to document something at the time in which it happened, you have lost your chance to document it at all.

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1 Documentation Name Class Period Date Read each question carefully regarding proper documentation techniques and then write T (true) or F (false) on the line next to the question. 1. You should always chart time, route, dose, and response to medications. 2. It is important to chart any verbal order, even if you did not hear it directly. 3. Only the first page of the chart needs to have the patient s name on it. 4. If you forgot to document something at the time in which it happened, you have lost your chance to document it at all. 5. It is acceptable to use abbreviations that are approved by your facility when charting, as long as the accepted list is available and maintained by your facility. 6. It is alright to pre-chart before something occurs, as long as you are reasonably sure that it will happen. You can always go back and change it later. 7. When charting a symptom, also chart your intervention and the patient s response. 8. Only document your own direct observations: what you see, hear, feel, or smell. It is not acceptable to chart what someone else tells you or what you think might have happened unless you observe it directly yourself. 9. There is no need to chart routine activities once a pattern has been established. 10. It is important that you chart when the event occurs instead of waiting until the end of the shift when you must rely on memory and may run out of time. 11. Keep charting limited to the patient himself/herself, even if a family member is included in the conversation. 12. If a patient refuses treatment, chart the response. 1

2 Name five types of documentation, give a brief description of each, and list at least three strengths and weaknesses of each type. a. Documentation Type : i. : ii. : b. Documentation Type: i. : ii. : c. Documentation Type: i. : ii. : d. Documentation Type: i. : ii. : e. Documentation Type: i. : ii. 2

3 Documentation Answer Key 1. Chart time, route, dose, and response to medications. TRUE. These four things should always be documented. 2. It is important to chart any verbal order, even if you did not hear it directly. FALSE. Never chart a verbal order that has not been directly heard. Go to the source to hear it directly. 3. Only the first page of the chart needs to have the patient s name on it. FALSE. Every page of a patient s chart should have the patient s name and date on it. 4. If you forgot to document something at the time in which it happened, you have lost your chance to document it at all. FALSE. Write the late entry, along with the date and time that you chart it, if you forgot to document something contemporaneously. However, keep in mind that notes made at the time an action or observation occurred are most credible. 5. It is acceptable to use abbreviations that are approved by your facility when charting, as long as the accepted list is available and maintained by your facility. TRUE. Abbreviations can be used, but only when they are among the list of accepted abbreviations of the facility. 6. It is okay to pre-chart before something occurs, as long as you are reasonably sure that it will happen. You can always go back and change it later. FALSE. Never blanket chart or pre-chart. Charting something that you didn t do is fraud and can be prosecuted as a criminal offense. 7. When charting a symptom, also chart your intervention and the patient s response. TRUE. 8. Only document your own direct observations: what you see, hear, feel, or smell. It is not acceptable to chart what someone else tells you or what you think might have happened unless you observe it directly yourself. TRUE. Document only what you have seen or observed yourself. For instance, if you come into a room and a patient is on the floor, note only that they are on the floor, not that they have fallen, as you did not see the actual fall yourself and that might not be the cause. 9. There is no need to chart routine activities once a pattern has been established. FALSE. All activities, even routine actions, should be documented. 10. It is important that you chart when the event occurs instead of waiting until the end of the shift when you must rely on memory and may run out of time. TRUE. 11. Keep charting limited to the patient himself/herself, even if a family member is included in the conversation. FALSE. In addition to charting the teaching and response of a patient, you should also document if a family member was involved. 12. If a patient refuses treatment, chart the response. TRUE. Both chart and report patient refusals. 1

4 Name five types of documentation, give a brief description of each, and list at least three strengths and weaknesses of each type. Documentation Type : Charting By Exception Sets standards for assessment and care Has guidelines printed on the form Promotes uniform nursing practice Makes abnormal trends obvious Progress notes May be very brief since they depend a lot on flow sheets Have large blank areas May intentionally omit routine care CBE notes can t be used in multidisciplinary charting They take a major time commitment to develop They require in-depth training All stages of the nursing process are not always evident especially nursing judgments or evaluations Isolated or unexpected events aren t documented The care plan isn t always revised Preventive/wellness issues aren t addressed Highlights abnormal data and makes it retrievable Isn t obscured by normal data Reduces charting time Requires fewer pages Predictable defined outcomes are required It can be difficult to ensure completeness It s difficult to automate this charting format This format also includes all the problems inherent in the SOAP format Users of this format report problems with double documentation Information repeated on nurses and doctors orders, flow sheets, and SOAP notes Subjective and objective information repeated on flow sheets The assessment and plan of the SOAP notes may be on the plan of care Documentation Type: FOCUS Progress notes are structured. It promotes the use of the nursing process and stresses the evaluation component. It s easy to track a particular problem. It promotes analytical thinking. It works in most clinical areas. It encourages addressing the patient s concerns, not just the problems. It changes the nurse s thinking patterns to concentrate on identifying a focus/focuses and which data relates to that focus. This is a short-term weakness until the nurse adjusts to this format. It requires monitoring to ensure that practitioners follow up on responses. 2 It can address health promotion and wellness. The structure is flexible. It s easy for others to understand. The language and process are uncomplicated. It s not restricted by a problem list. The format can be automated. It can be used in multidisciplinary charting. Some difficulty is evident in categorizing data and identifying responses. Terminology may be inconsistent between the FOCUS column and the way the information is noted in the care plan, or from one note to the next. Progress notes may evolve into narrative format.

5 Documentation Type: Narrative Is a simplified method Allows the author to control what is said Promotes chronological documentation easy to document and track timing of events if documentation is done correctly Works in all clinical environments Is easy to teach or learn Requires no special form other than blank paper The author is given no guidance about what to say. The author must learn through experience, decide what is important to document, and develop his or her own system for organizing a note. This freeform can produce notes that could be any of the following: Fragmented; disjointed; noninformative, rambling; subjective; inconsistent with what is documented from one author to the next; too wordy making it difficult to pick out patient trends and problems. This format requires a lot of time to personalize data for each patient.it s difficult to retrieve information, since everything must be read to find a certain fact. It's difficult to retrieve information, since everything must be read to find a certain fact. The patient outcomes may not be consistently documented, so it becomes hard to track progress or identify lack of progress. Documentation Type: SOAP (SOOOOAP) They address specific problems. The structure gives guidance, so information is presented in an organized manner. The structure of these notes guides the nurse s thoughts to include the patient s thoughts or concerns as well as data the nurse has about the problem, assessment, planning of care, evaluation, and revision. The notes are organized the same from author to author. The problem list is helpful in these ways: To alert all caregivers about problems being addressed To ensure that all problems are addressed To facilitate data retrieval about a particular problem Notes show the following: Continuity of care Evaluation and resolution of problems The format promotes documentation of the nursing process. It eliminates nonessential data This format is difficult to use when any of the following is true: There is a fastpaced change in the patient s condition; the problem list is not used or kept current; all components of the note are not used. Routine care is difficult to document and may not be reported if flow sheets are not used. Frequent repetitive charting is necessary, since data may relate to 3 more than one problem, and the plan must be in the note and on the plan of care form. Many people have difficulty deciding where information needs to be placed is it subjective or objective data? Is the data assessment or evaluation? This format is time-consuming to write and read due to the repetitive charting.

6 SOAP notes are extremely difficult to work with for nurses who have 8 to 12 hours of constant contact with a patient. They are best used in clinical situations where nurses make summary notes for a day, week, or month at a time. The format isn t suited for fast patient turnover. Documentation Type: Electronic Charting is legible. Several people can have access to the same record at the same time. Prompting is available to remind the person charting about what to chart. All changes to the record can be tracked. The system can be modified to meet facilities particular needs. Notes can be organized the same from author to author. You always know where the chart is. This method promotes documenting the nursing process. It decreases problems in maintaining adequate charting forms and supplies. The facility must make a major cash investment for equipment, software, and training. Many people need to be trained to use a computer and to overcome their fear of computers. If the hardware or software crashes, you lose access to the chart. This method requires a major psychological change for staff. They must overcome their fear of computers and must adjust how they work and organize their time. Documentation may be inaccurate if the practitioner doesn t carefully read each phrase picked from a menu. 4