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Online Companion: Fundamentals of Nursing Standards and Practice 2E
Recording and reporting
of nursing care are major communication techniques nurses use to share information.
These activities form the basis for client-based decision-making and continuity
of care. Nurses rely on documentation tools that support the implementation
of the nursing process. The system used for documentation within a health care
agency must provide a way to organize the tools used for documentation and to
demonstrate each phase of the nursing process. The purposes of health care documentation
include: to demonstrate professional responsibility and accountability, to communicate
the care provided to the client, to educate health care professionals, to provide
data for clinical research, and to meet legal and practice standards. The various
documents that comprise a medical record are described in Chapter 26. There
are special considerations for the consent form that is part of every client's
record. The client is asked to sign a consent form for each of a variety of
diagnostic and treatment procedures that are performed in the hospital or clinic.
Nurses are responsible for insuring that the client understands the procedure
and has signed the consent form. The client may have advance directive statements
and these become part of the medical record. Documentation of nursing care is
mandated by the nurse practice acts of each state and is part of the profession's
standards of care. The Joint Commission on Accreditation of Health Care Organizations
(JCAHO) requires that each client have an individualized plan of care that is
developed with client and or family participation by an interdisciplinary planning
group. The prospective payment system (PPS) of reimbursement enacted by the
federal government uses the documentation of appropriate care as a basis for
payment for services. The PPS system looks for documentation of client teaching
and discharge planning. In Chapter 26, the authors have compiled concise and
useful guidelines for general documentation and for assessment-specific documentation.
The requirements for effective documentation are these: accuracy, use of a common
vocabulary, legible writing, use of the date and time, charting done in a timely
manner to avoid omission of data, a method to document a medication error, and
a plan to maintain confidentiality. The various methods used for documentation
are described in the chapter; the authors offer samples of documentation. The
forms used for recording data are these: Kardex, flow sheets, progress notes,
and discharge summaries. These forms are described and examples are provided
in Chapter 26.
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