Frequently Asked Questions
Chapter 16: Documentation and Reporting

What are the purposes of documentation in health care?

The purposes of documentation in health care are (1) to communicate information validating the care provided to the client, (2) to educate nursing and other health care students, (3) to conduct research, (4) to document that care was performed according to existing laws and standards (e.g., informed consent, advance directives, durable powers of attorney, American Nurses Association Standards of Care have been met, state Nurse Practice Acts, and Joint Commission on Accreditation of Healthcare Organizations), and (5) to provide data for reimbursement.

What is the difference between an advance directive and a durable power of attorney?

An advance directive is a statement made by clients that defines care they deem acceptable if they become incapacitated and outlines the types of life-sustaining procedures they will permit if they become unable to make their own decisions at a later time. The durable power of attorney allows the client to appoint a person to make health-related decisions when the client is incapable of making them.

What type of care plan does the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) require?

JCAHO requires an individualized, interdisciplinary care plan with evidence of involvement of the client or family.

How is documentation related to reimbursement?

Peer review organizations (PROs), consisting of physicians and nurses, monitor and evaluate the quality and appropriateness of care given. Peer review, required by the federal government, evaluates the intensity of services and severity of illness, comparing them with medical records from similar health care agencies. Additionally, the federal enactment of diagnosis-related groups (DRGs) changed reimbursement from a cost-per-case formula to a prospective payment system (PPS). Reimbursement depends on appropriate documentation and evidence of the care given. Proper documentation is also important to document that the Consolidated Budget Reconciliation Act (COBRA) requirement for institutions to stabilize clients before transferring them to another institution is met. Documentation concerning client transfers must include the chronology of the event, measures taken or treatment implemented, the client’s response to treatment, and the results of measures taken to prevent the client’s condition from deteriorating.

What are some guidelines for assessment-specific documentation?

When documenting assessments, the nurse should (1) record positive and negative findings, (2) document parts of the assessment that are omitted or refused by the client, (3) avoid judgmental language, (4) avoid evaluative statements, (5) state time intervals precisely, (6) use specific measurements, (7) use diagrams when appropriate, (8) refer to anatomical landmarks, (9) use the face of the clock to describe findings that are In circular pattern, (10) document any change in the client’s condition from prior assessments, and (11) document observations rather than nursing actions.

What should be recorded on the nurses’ notes when the nurse makes a medication error?

The following should be recorded on the nurses’ notes when the nurse makes a medication error: the name and dosage of the medication, the time it was given, the client’s response to the medication, the name of the practitioner who was notified of the error, the time of the notification, the nursing interventions or medical treatment used to counteract the error, and the client’s response to treatment.

What are the advantages of computerized documentation?

Computerized documentation saves documentation time; increases legibility and accuracy; provides clear, decisive, and concise key words; facilitates statistical analysis of data; enhances implementation of the nursing process; enhances critical thinking and decision making; and supports multidisciplinary networking.

What are the advantages of point-of-care charting?

Point-of-care charting controls operating costs, complements existing information systems, eliminates redundant data entry, allows the nurse more one-on-one time for client care, and provides client information to the health care team in a timely fashion.

What should be included in the summary (end-of-shift) report?

The following should be included in the summary (end-of-shift) report: background data, primary medical and nursing diagnoses and priority problems, client’s risk problems, changes in conditions, changes in interventions and treatments, progress toward expected outcomes, adjustments in the plan of care, and client or family complaints.

What is the purpose of the incident report?

The incident report is used to document any unusual occurrence or accident in the delivery of client care. The incident report informs the facility’s administration of the incident so that risk management personnel can consider changes that might prevent similar occurrences. The incident report also informs the facility’s insurance company to a potential claim and the need for further investigation.

What should the incident report include?

The incident report should include the date, time, and place of the occurrence; the person(s) involved in the incident, including any witnesses; a description of the exact occurrence; any assessments and acts to provide care; and notification of supervisor and physician(s).