Methods of Documentation

Question 1

Documentation of Patient Assessment Data

Answer 1

Within the EHR, nurses routinely document patient physiologic data and
routine care using flow sheets (graphic records) that are organized by
body system and navigated through use of the computer mouse with a
series of tabs or rows (Fig. 26.3). These forms allow you to quickly and
easily enter assessment data about a patient, such as vital signs, admission
and or daily weights, and percentage of meals eaten. They also facilitate
the documentation of routine, repetitive care, such as hygiene measures,
ambulation, and safety and restraint checks. These documents provide
current patient information accessible to all members of the health care
team and help team members quickly see patient trends over time.

Question 2

Progress Notes

Answer 2

Health care team members monitor and record the progress made toward
resolving a patient’s problems in progress notes. Health care providers
write narrative progress notes in one of several formats or structured notes
within the EHR. Narrative
documentation is the format traditionally used by nurses and health care
providers to record patient assessment, clinical decisions, and care
provided; it consists of a storylike format to document information. e.g. 1915: Adhering to bed rest as ordered. Left lower extremity is swollen;
calf circumference is 30 inches. Areas of redness that are warm and tender
to touch are noted over anterior (3 cm by 4 cm) and medial areas (3 cm by
3 cm) of left leg. Left lower leg elevated on one pillow. Heparin infusing at
3600 units/hour via 20-gauge peripheral IV in left lower forearm. Site
without redness, swelling, or drainage. Verbalizes sharp throbbing leg
pain rated at 8 on a 0-to-10 scale. Pedal pulses 3+ bilaterally. Capillary refill
in toes of both feet is less than 3 seconds. Oxycodone/acetaminophen 2
tablets (PO) given for pain as ordered. Chris Banks, RN.
2000: States, “The pain medication really helped.” Rates pain in left
lower leg at 4 on a 0-to-10 scale. Comfort level goal is 4/10. Chris Banks, RN.
When entering a narrative progress note in the
EHR, be clear and accurate when describing subjective and objective
patient assessment findings, as well as any interventions taken to resolve
patient problems and maintain patient safety.

Examples of Nursing Documentation in
Different Formats:

• Narrative Note: Patient states, “My leg is so swollen. I’m worried about this blood
  clot.” Is asking question about medications and how DVT will be
  treated. Alert and oriented; responds appropriately to instruction.
  Discussed importance of bed rest and the reason for treatment with
  heparin infusion.
• PIE: A PIE note has a specific nursing focus.
  • P: Nursing problem or diagnosis—Lack of Knowledge related to
  inexperience with disease condition
  • I: Interventions that will be used to address the problem—Provided
  brochure on anticoagulation therapy for DVT. Explained rationale for
  bed rest and daily blood tests to check anticoagulation levels.
  Explained that heparin infusion will be stopped when PT/INR is at
  therapeutic level and that he can expect to take warfarin for about 6
  months until clot resolves.
  • E: Nursing evaluation: Patient states, “I’m worried about the blood
  clot, but I understand how it is being treated.” Able to teach back and
  verbalize that the heparin infusion will be stopped when PT/INR tests
  are “normal.” Also states that he expects to take warfarin for about 6
  months until clot in leg dissolves.

Focus Charting
- Uses a DAR format to report problems. DAR notes address patient
concerns such as a sign or symptom, condition, nursing diagnosis,
behavior, significant event or change in condition.
• D: Data (subjective and objective)—Patient states, “My leg is so
swollen. I’m worried about this blood clot. Do you know how they
are going to treat it?”
• A: Action or nursing intervention—Provided brochure on
anticoagulation therapy for DVT. Explained rationale for bed rest and
daily blood tests to check anticoagulation levels. Explained that
heparin infusion will be stopped when PT/INR is at therapeutic level.
• R: Response of the patient—Able to teach back and verbalized that
heparin infusion will be stopped when PT/INR reaches “normal
level” and that he can expect to take warfarin for 6 months after
discharge until clot is fully resolved.

SOAP Note—Used By All Health Care Disciplines
- S: Subjective—Patient states, “My leg is so swollen. I’m worried
about this blood clot. Do you know how they are going to treat it?”
• O: Objective—Patient asking question about medications and how
DVT will be treated. Alert and oriented; responds appropriately to
instruction.
• A: Assessment—Patient lacks knowledge regarding anticoagulation
therapy, seeking information about therapy.
• P: Plan: Discussed importance of bed rest and the reason for
treatment with heparin infusion. Provided brochure on
anticoagulation therapy for DVT. Explained rationale for bed rest and
daily blood tests to check anticoagulation levels. Explained that
heparin infusion will be stopped when PT/INR is at therapeutic level
and that he can expect to take warfarin for about 6 months until clot
resolves.

Question 3

Charting By Exception

Answer 3

The philosophy behind charting by exception (CBE) is that all standards
for normal assessment findings or for routine care activities are met unless
otherwise documented. Exception-based documentation systems
incorporate standards of care and use clearly, predefined statements for
the nursing documentation of “normal” body system findings. These
normal findings called “within defined limits” (WDL) or “within normal
limits” (WNL) consist of wri􀄴en criteria for a “normal” assessment for
each body system. Documentation within a computerized system allows
nurses to select a WDL statement or to choose other statements from a
drop-down menu that allow description of any unexpected assessment
findings or assessment findings that deviate from the WDL definition. The SBAR or ISBAR format is a commonly used framework for a
narrative note when exceptions occur. Both are also popular formats for
verbal reporting (see Chapter 24). When changes in a patient’s condition
develop, a narrative progress note must include a thorough and precise
description of the effects of the changes on the patient and the actions
taken to address those changes.