DOCUMENTATION

CHARTING OR
DOCUMENTATION
IS THE PROCESS OF PREPARING A COMPLETE
RECORD OF A PATIENT’S CARE. ACCURATE,
DETAILED CHARTING SHOWS THE EXTENT AND
QUALITY OF THE CARE YOU’VE PROVIDED, THE
OUTCOME OF THAT CARE.
IMPORTANCE OF PROPER CHARTING:
 Establish your professional responsibility and
accountability.
 A vital tool communication among health care team
members.
 Decisions, actions, and revisions related to the patient’s
care are based on charting from various team members.
 Shows the high degree of collaboration among health care
team members.
 Be easily retrievable and readable as well .
 USERS
 Other members of the health care team
 Reviewers from accrediting, certifying, and licensing
organization
 Quality-improvement monitors
 Peer reviewers
 Medicare and insurance company reviewers
 Researchers and teachers
 Lawyers and judges
*Notes of Nursing, clear, concise, organized manner
 Roles of charting
1. it’s a mode of communication among health care
professionals.
2. it’s checked in health care evaluation.
3. it’s legal evidence that protects you.
4. it’s used to aid research and education
5. it helps facilities obtain accreditation and license.
6. it’s used to justify reimbursement request.
7. it’s used to develop improvements in the quality of care.
8. it indicates compliance with your nurse practice act.
9. it established professional accountability.
 TYPES OF CHARTING

1. TRADITIONAL NARRATIVE
CHARTING
2. PROBLEM ORIENTED
MEDICAL RECORD SYSTEM
3. PROBLEM-INTERVENTION-
EVALUATION SYSTEM
4. CHARTING-BY-EXCEPTION
5. FOCUS CHARTING
RULES ON HOW TO CHART
1. Stick to facts – what you see, hear, smell, feel, measure
and count.
2. Avoid labeling – objectively describe patients behavior.
3. Be specific – facts are presented clearly and concisely,
express observation in quantifiable terms.
4. Use neutral language – don’t use inappropriate comments
or language its unprofessional.
5. Eliminate bias – don’t use language that suggests a
negative attitude toward the patient.
6. Keep the record intact – soiled entries are not discarded.
7. Copy it and put the copy and the original in the chart.
8. Write recopied from page – on the copy and recopied on
page-on the original.
RULES ON WHAT TO CHART
1. Chart significant situations – recognize
legally dangerous situations as you give
patient care.
2. Chart complete assessment data – it is the
key factor in many malpractice suits. Be sure
to chart everything you do and why.
3. Document discharge instructions – written
inadequate or incorrect instructions that may
result to injury may hold you liable.
 RULES ON WHEN TO CHART – TIMELINESS OF
ENTRIES IS A MAJOR ISSUE IN MALPRACTICE SUIT

DOCUMENT NURSING
CARE WHEN YOU
PERFORM IT OR SHORTLY
AFTERWARD OR ELSE
YOUR CREDIBILITY IS AT
STAKE.
RULES ON WHO SHOULD CHART
1. No matter how busy you are, never ask
another nurse to complete your charting
and never complete another nurses
charting. It destroys credibility and value
of the record.
2. second hand observations are hear say
evidence.
 CHARTING DON’TS
Charting mistakes are legal land mines.
Avoid them:
1. Don’t record staffing problems.
2. Don’t record staff conflicts.
3. Don’t mention incident reports.
4. Don’t use words associated with errors like “by
mistake”.
5. Don’t name a second patient instead use
“roommate”.
6. Don’t chart casual conversations with colleagues.
 Assessment checklist:
Nursing Process • Physical / Initial V/S
• Psycho-social
• Mental-Spiritual
Gather • Environmental
Progress Notes:
Data •Diagnostic Results
Focus charting
W/ DAR Form
Evaluate Analyze Maslow’s
Hierarchy
data
Implementation:
• Medication sheet Implemen
* A.B.C. D
t Plan
• Vital signs sheet kardex
• I.V. fluids sheet
• I & O sheet
• Other special form
 Four Elements of Focus Charting

Gather
 Focus Evalua Data
te
 Data
Analyz
 Action e Data
 Response
Implem
ent

Plan
 FOCUS – identifies the content or purpose of the
narrative entry and is separated from the body of
the notes in order to promote easy data retrieval
and communication.
1. To describe a patient 2. To identify an exception to the
problem/focus/concern expected outcome.
from the care plan. - When the significant findings
- When the purpose of the or an outcome is not as
note is to evaluate progress expected (the exception).
toward the defined patient
outcome from the plan of Examples:
care.
wheezes left base
Examples: Nausea
Self-care eating
Skin integrity
Activity tolerance
3. To document a new 4. To document an acute
finding. change in patient’s
- When the purpose of condition.
the note is to - When there has been an
document a new sign event or new patient
or symptom or a new condition.
behavior.

Examples:
Examples:
Respiratory distress
Constipation Seizure
Chest pain Code Blue
Disoriented
5. To document a
significant even or Examples:
unusual episode in •Admission
patient care. •Pre-assessment (specify, procedure)
- When: •Post-assessment (specify, Procedure)

(a) responsibility for • Assessment Pre-transfer

patient care •Assessment Post-transfer
changes from one • Assessment Discharge status
department to • Transfusion (PRBC, FFP etc…)
another.
(b) a significant
treatment/
intervention took
place.
6. To document an activity 7. To describe all specifics
or treatment was not regarding patient/ family
carried out. teaching.
- When treatment or - This is in compliance with
activity in the flow sheet/ a standard of care.
checklist was not
Examples:
provided to the patient
or was different from the Health teaching:
standard of care. (specify, topic)
Examples:
 Refusal of physical
therapy
DATA
- is the subjective and/ or objective information supporting
the stated focus or describing the observation at the time of a
significant event.

 Subjective data records the problem in the patient’s “own”

words (if the patient is not the informant, it should be noted. Do
not attempt to interpret and/or translate the patient’s subjective
cues.
 Objective data include the quantitative observations. This
includes vital signs, physical assessment, and laboratory
results.

psychosocial observation, for example an observation of restlessness.

ACTION
– describes the nursing interventions (past, present or
future).

Basic interventions
– Activities of Daily Living (ADL)
• Bathing
• Feeding
• Toileting
• Mobility
• Dressing
RESPONSE
– describes the patient outcome to interventions or
describes how the plan goals have been attained.
Information from all three categories
(Data, Action, Response) should be
used only as they are relevant or
available.
DATA and ACTION are recorded at
one hour, and RESPONSE is not
added until later, when the patient
outcome is evident.
Date, Shift FOCUS Data, Actions, Response
& Time

M AT
F O R
Date &Time Focus Data, Action, Response

1-27-07 Pain at IV site D – “Miss, masakit ang pinaglagyan ng IV

8:00 ko.”
Check site of IV, found beginning signs of
infiltration.
8:10 A– Remove IV, change the whole system,
reinserted the new set aseptically into the
distal portion of basilic vein, left arm
anchored, splint applied, advised to call
nurse for any presence of pain
8:20 R—”Wala na ang sakit ng pinanggalingan
ng IV ko.”
M. VILLAR, RN
DATA/ TIME FOCUS DATA, ACTION, RESPONSE
2/22/03 Chest pain D: “Sumasakit and dibdib ko”
10:00am Midclavicular line pain of 4/5
Radiating to jaw. Relieved by
Rest. VS stable.
A: Encourage to rest on bed.
Medicated with Isordil 5mg
12nn R: Resting in bed “Navawasan ang sakit ng
dibdib ko.” Rating of 2/5.
B. Aquino, RN
DATA/ TIME FOCUS DATA, ACTION, RESPONSE
2/22/03 Fever D: “Mainit ang pakiramdam ko” Skin warm to
6:00am touch. Temperature is 39°C.
A: Tepid sponge bath given. Encouraged to
Increase fluid intake. Referred to Dr. Tan.
Paracetamol 500mg 1 tab. po given.
8:00nn Fever R: “Pinagpawisan na ako.” Temperature is
38°C. Tolerated 2 glasses of water
A: Continue tepid sponge bath. Changed
Clothing. Will monitor temperature.
J.BINAY, RN
DATA is used alone when the purpose of the
note is to document assessment finding and
there is no flow sheet/ checklist for that
purpose.
DATA/ TIME FOCUS DATA, ACTION, RESPONSE
2/22/03 Post-transfer D: Received from RR via
2:20 pm Assessment Stretcher, awake and alert,
VS stable, IV right forearm
Patent, foley in place with
Clear yellow urine, dressing
on RLQ is clean and dry,
Moving all extremities voluntarily.
“Minimal incisional
Pain at this time, rating of
3/5.”
A. Aquino, RN
ACTION and RESPONSE are repeated without
additional data to show the sequence of decision
making based on evaluating patient response to the
initial intervention.
 DATA/ TIME FOCUS DATA, ACTION, RESPONSE
2/22/03 Nausea D: “I feel like my stomach is filling up with
10:00am Pressure again and I’m nauseated.” Abdomen
Round and soft. gastrostomy bag at body level.
Rare bowel sounds.
A: Gastrostomy bag lowered
R: “I feel better now.” Approximitely 200 cc.
Golden watery feces removed and much flatus.
10:10am A: Keep gastrostomy bag lower than body level. Monitor
Abdominal status.
Tolerated at lower body level. Document time and
amount of drainage and discomfort. Patient
instructed to call Nurse when uncomfortable.
R: “I understand plan.”
M. Aquino. RN
Begin the note with ACTION when
the patient's interaction beings with
intervention or when including data
would be unnecessary repetition.
DATA/ TIME FOCUS DATA, ACTION, RESPONSE
2/22/03 Health A: Patient instructed on the
2:30 pm Teaching: Actions and side effects of
Digoxin Digoxin. Given digoxin information
Card. Discussion when
He would call the physician
About the medicine.
R: Return demonstration of
Radial pulse. “I understand
Purpose of medication.”
M. Aguino, RN.
RESPONSE is used alone to indicate a
care plan goal has been accomplished.
DATE/TIME FOCUS DATA, ACTION, RESPONSE
2/22/03 Health R: Patient demonstrated he is
1:00 p.m. Teaching Able to change his own abdo-
Dressing minal dressing using aseptic
Change technique.
M. Aquino, RN
DO’S OF DOCUMENTATION
1. DO read what other providers have written before
providing care and before charting your care.
2. DO time and date all entries.
3. DO write the time you put your pen on the paper.
4. DO use flow sheet/ checklist. Keep information on
flow sheet/ checklist current.
5. DO chart as you make observations and provide
care.
6. DO write your own observations and sign your
own name. sign and initial each time entry. (M.
Aquino, RN).
7. Do record exactly what happens to patient and
care given.
8. DO be factual and complete.
9. DO draw a single line through an error. Mark this
entry as “mistaken entry” and sign your initials.
10.DO use next available line to chart.
11.DO document patient’s current status and
response to medical care and treatments.
12.DO write legibly.
13.DO use ink.
14.Do use accepted chart forms.
15.Do use only approved abbreviations.
Tips for better documentation
If you are ever involved in a malpractice case, what you
documented, how would you do documented it & what
you did not document will heavily influenced the
outcome. Here are some tips on how to document so that
incase of a law suit your records work for you & not
against you.

1. Use the appropriate form & document in it.

2. Record the patient’s name & identification number on
every page in the his charts, to avoid any possible
confusion.
3. Record the complete date & time of each entry. Be
specific avoiding general terms & vague expressions
that could be interpreted in different ways.
4. Use standards abbreviations only.
5. Use a medical term only if you are sure of its meaning.
6. Document symptoms by using patients own words.
7. Document any nursing actions you take in response to a
patients problem.
For example:
“8pm-medicated for incision pain” Be sure to include the
medication route & site.
8. Document the patients response to medications & other
treatments.
9. Document safeguards you used to protect the patients.
For example:
“raised side rails” or “applied safety belts”.
10. Should any incident occur, document it in two places
once in your progress report & another in a separate
incident report.
11. Document each observation. Failure to document
observations will produce gaps in the patients records,
suggesting that you neglected the patient.
12. Document procedures only after you have performed
them never in advance.
13. Write on every line, don’t insert notes between lines or
leave empty spaces for someone else to insert a note.
14. Sign every entry.
15. Document an omission as a new entry. Never backdate
or add to previously written entries.
16. Draw a thin line through an error, never erase one. Write
“mistaken entry” above the line & underneath your
signature.
17. Document only your own care never someone else.
Except when documenting procedure done by nursing
assistants - care giver/nursing aide.