Communication is a dynamic, continuous, and multidimensional process for sharing information as determined by standards or policies. Reporting and recording are the major communication techniques used to direct client-based decision making and continuity of care. The purposes of health care documentation 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.

Documentation is defined as written evidence of (1) the interactions between and among health professionals, clients, their families, and health care organizations; (2) the administration of tests, procedures, treatments, and client education; and (3) the results or client’s responses to these diagnostic tests and interventions.

Nursing documentation includes assessment data, risk factors and/or an identified alteration in functional health patterns, the nursing diagnosis, goals and expected outcomes, plan of care, and implementation. Nurses notes should communicate the date, time, and purpose of nursing assessments and interventions; the nursing diagnosis, using NANDA terminology; the expected outcomes and plans for the client; the implementation of the plan; the evaluation of the client; and any revisions to the planned care. Legally, the entries in a chart should (1) be legible; (2) be spelled correctly with appropriate grammar; (3) reflect the use of authorized abbreviations only; (4) be factual and time-sequenced accurately; and (5) contain no omissions, blanks, or unused spaces.

Effective documentation requires the use of common vocabulary; legibility and neatness; the use of only authorized abbreviations and symbols; factual and time-sequenced organization; and accuracy, including any errors that occurred. Medication errors should be recorded on incident reports, the medication administration record (MAR), and the nurses’ notes. An important principle when documenting medication administration is to never document a medication before it is given. All documents related to client care are confidential and clients must sign a release to have their information released, specifying what type of information may be released and to whom it may be released.

The methods used for documentation include narrative charting, source-oriented charting, problem-oriented charting, PIE charting, focus charting, charting by exception (CBE), computerized documentation, and case management with critical paths. Narrative charting, the traditional form of nursing documentation, is a story format documenting client status, interventions, treatments, and responses. Narrative charting is often disorganized, fails to reflect the nursing process, is time-consuming, and yields information that is difficult to retrieve. Source-oriented (SO) charting is a narrative recording by each member (source) of the health care team charts on separate records. SO charting is time-consuming and can lead to fragmented care.

Problem-oriented medical record (POMR) charting was introduced by Dr. Lawrence Reed to focus on the client’s problem. POMR is a structured, logical format of narrative charting, using “SOAP,” where S means “subjective data,” O means “objective data,” A means assessment data, and P means “plan.” Some institutions add, intervention, E, evaluation, and R, revision, to the SOAP format. POMR is sometimes altered to become the problem-oriented record (POR). The critical components of POMR/POR are the database; the problem list; the initial plan; and the progress notes, based on the SOAP, SOAPIE, or SOAPIER format.

PIE charting was developed by nurses at the Craven Regional Medical Center to streamline documentation. “PIE” stands for Problem, Intervention, and Evaluation. PIE charting eliminates the need for the traditional nursing care plan because the ongoing plan of care is incorporated into daily documentation. Focus charting focuses on client problems or concerns, which could include a concern about a test or surgical procedure as well as health problems. Charting by exception (CBE) is documentation of only deviations from preestablished norms. A thorough baseline assessment is documented and descriptions of exceptions should be as detailed as possible.

Computerized documentation is the use of technology to document client care. Hospital information systems (HIS) include nursing information systems (NIS). The NIS supports nursing administration; standardized client care information; and linkages between nursing practice, education, and research. Point-of-care charting allows health care providers to access client information at the bedside through a handheld portable computer, which is then uploaded into the hospital’s main computer.

Computerized documentation facilitates the use of case management for client care. Case management is a method used to organize client care throughout an episode of illness so that specific clinical and financial outcomes are achieved within an allotted time frame. A critical pathway (critical path), an abbreviated summary of key indicators from the case management plan, is used to monitor and document that interventions are performed on time and that client outcomes are achieved on time. Variations (variance) are goals that are not met or interventions that are not performed within the time frame.

There are several types of forms used in the various forms of nursing documentation. A Kardex (a client profile and client summary sheets) is a summary of the tasks done for a client. The Kardex is used throughout each shift, is used during the shift report, and is usually not a part of the client record. Flow sheets document assessments, interventions, and changes in a client’s condition through checklists or small boxes for recording data. Nurses’ progress notes document the client’s condition, problems, and complaints; interventions; responses to interventions; and achievement of outcomes. Discharge summaries document the client’s status at admission and discharge, a brief summary of the client’s care, intervention and education outcomes, resolved problems, continuing care needed, and client instructions.

Computerized documentation has facilitated the development of several trends: the Nursing Minimum Data Set, nursing diagnoses, the Nursing Intervention Classification (NIC), and the Nursing Outcomes Classification (NOC). The Nursing Minimum Data Set (NMDS) includes elements that are contained in data sets and can be abstracted for studies on effectiveness and costs, including demographics; administrative services (such as admission and discharge dates, payer, or health care record number); and nursing care given, including nursing diagnosis, interventions, outcomes, and intensity. Nursing diagnoses are clinical judgments about individual, family, or community responses to actual or potential health problems or life processes. The Nursing Intervention Classification (NIC) is a comprehensive standardized language for nursing interventions. The Nursing Outcomes Classification (NOC) is a taxonomy of patient outcomes that are sensitive to nursing interventions.

Nurses have a variety of mechanisms to communicate with each other over time about a client’s needs and conditions. Reporting is the verbal communication of data regarding the client’s health status, needs, treatments, outcomes, and responses. The types of reports are summary reports (end-of-shift reports), walking reports, telephone reports and orders, and incident reports.