Chapter 20 DOCUMENTATION AND REPORTING SKILLS

OBJECTIVES

• Define the key terms/concepts

• Discuss the legal and ethical considerations associated with documentation and report writing

• Identify the purpose of documentation

• Outline the guidelines for documenting client information

• Identify the types of documentation formats in use

• Review the patient classification system associated with residential aged health care

• Review case management and critical pathway systems

• Determine the principles for reporting client information

• Develop and practise the skills of verbal and written reporting and recording in the delivery of client care

KEY TERMS/CONCEPTS

case management

charting by exception

critical pathways

flow charting

Kardex

objective data

resident

resident classification scale (RCS)

SOAP format

subjective data

CHAPTER FOCUS

Verbal reporting and documentation are two ways in which communication takes place among members of the health care team. Both are an account of what has been assessed or observed about a client and the care that has been implemented. Health care team members rely on reports and records to deliver care that is directed towards mutually agreed goals. Continuity of care and the pursuit of common objectives depend upon effective communication between members of the health care team, which involves accurate and precise verbal and written reporting and recording of information.

LIVED EXPERIENCE

After working in acute care for so long I was overwhelmed with the amount of paperwork involved with aged care. It took a while to get my head around all the jargon but I now understand why it is all so important.

Kelly, Registered Nurse

Documentation of nursing interventions and management associated with client health status serves two broad purposes: it is a means by which members of the health care team can provide appropriate care for the client, while also becoming a historical outline of the client’s care for future reference if needed; and it is a contemporaneous record of events that have taken place and is therefore most likely an accurate record of those events (Crisp & Taylor 2005).

Both these purposes have legal implications for all concerned. As a means of client care, clinical records can be used in court either to prove or to refute a claim of negligence on the part of a health professional. Given the contemporaneous nature of a client’s clinical records, the courts may use them to determine what care was or was not given, and the condition of the client at any particular time. Nurses therefore need to be mindful of these potential legal uses and develop their writing skills accordingly.

In addition, nurses need to meet professional and ethical responsibilities to maintain accurate records in relation to the treatment and care given to clients. For nurses, sound documenting skills are unquestionably good nursing practice and essential in facilitating effective nursing care.

PURPOSE OF DOCUMENTATION

The purpose of documentation is to facilitate optimal client outcome through communicating accurate, objective and contemporaneous descriptions of clients’ health status and ongoing care. Documentation completed through professional and accurate writing, with legislative and ethical requirements in mind, helps to ensure that continuity of client care is provided. All clients require documentation, which includes records of assessment, diagnosis, planned interventions and subsequent care evaluations (Crisp & Taylor 2005).

Documentation facilitates:

• Communication of relevant clinical data between appropriate people

• Assessment of client health status, existing needs and the care provided by health professionals

• Auditing of service standards and adherence with legislative and ethical requirements

• Education and research

• Compliance with legal requirements

• Maintenance of professional standards.

Records, which promote continuity of care, are the means by which various members of the health care team communicate information about the client’s condition and the type of care that has been implemented. Written records (progress notes) provide permanent and accurate assessment of clients, their health status and progress, and the data necessary to plan and implement care. As part of quality assurance programs, health care agencies perform audits in which the information contained in client records is reviewed on a regular basis. Audits are performed to determine the degree to which specified quality assurance standards have been met (Berglund & Saltman 2002).

Written records provide a great deal of information, for example, about nursing diagnoses and evaluation of care that has been implemented, which may be used for educational purposes. The information contained in records may also serve as a source of data for research. Records also become a legal document, for example, if a client takes legal action against a health care agency, client records can be used as evidence in courts of law, where they are read and interpreted by lawyers. In addition, some records are now accessible by clients under the Freedom of Information Act (1982). Written records assist to ensure the continuity of client care through professional, accurate and contemporary documentation.

The two most commonly used record formats are the traditional source records and the problem-oriented records. In the source method, information is grouped according to its source; for example, the record is divided into the nurse’s notes, the medical officer’s record, laboratory reports and the physiotherapist’s report. Using this method each member of the health care team uses a separate section of the record to record data. While this method of recording enables each category of health care team member to make detailed entries, it does lead to the fragmentation of data, as the information is not written according to the client’s identified problems.

The problem-oriented method groups information from all members of the health care team into sections according to a client’s specific health problems, whereby each member of the team contributes to a single list of identified client problems. When this system is used it is easy to recognise and locate the client’s health care problems on a single record. While each health care agency adopts its own record format, many use a problem-oriented system of total client recording that includes all the information relevant to a client’s care (Berglund & Saltman 2002).

DOCUMENTATION GUIDELINES AND PRINCIPLES

Documentation must always be completed in a professional, accurate and objective manner. Factors that are to be considered when completing documentation in relation to care or treatment provided to a client include:

• Entries should be contemporaneous (as it happens) with the event and recorded in chronological order

• Even routine observations and assessments of changes of a client’s condition must be recorded; if no entry has been made it may be inferred that no observation or subsequent care was provided

• Ink is used, as pencil does not provide a permanent record

• Writing is neat and legible, as illegible entries can be misinterpreted

• The client’s full name, hospital number and other pertinent details are clearly stated on each sheet

• The date and time are included for each entry

• Only approved abbreviations are used, to avoid misinterpretations

• Correct spelling is used; for example, in relation to recording medications

• Any errors made are not erased or scratched out. Instead, the nurse should draw a single line through the error, write the word ‘error’ and initial it or sign their name. Under no circumstances should any form of white out (e.g. Liquid Paper, Tippex) be used when documenting in progress notes or assessment entries.

• No lines or spaces are left. A line should be drawn through the blank space in a partially completed line of writing to prevent others from recording in a space with someone else’s signature

• Nursing actions are not recorded before they have been performed. Once performed they are recorded immediately to avoid errors or omissions

• Recording is performed in a logical and sequential manner. An organised record, for example progress notes, addresses each topic thoroughly before a new topic is introduced

• The information is accurate, concise and factual. Objectivity of entries is maintained by reflecting on what has actually been seen, heard, smelt or touched by the nurse making the entry. Subjective statements and assumptions should be avoided. Information needs to be specific and the nurse must avoid using ambiguous statements in which the meaning is unclear

• When recording subjective data the client’s own words are used whenever possible, using quotation marks to indicate that the statement is a direct quote

• Each entry is signed by the person who records it. Most health care agencies require that a full signature, printed surname and designation is included; for example, Jane Smith (RN Div 2)

• The nurse adheres to the health care agency’s policies regarding charting and documentation

• Confidentiality is respected; for example, avoid leaving documentation in an area where it can be read by unauthorised persons. Nurses are legally and ethically required to maintain confidentiality about any information relating to a client

• Transcription of information should be avoided whenever possible, as this practice increases the potential for error to occur (Crisp & Taylor 2005).

COMPUTERS

In major health care agencies computers are used to record client information. With computerised systems recording significant amounts of client information it is important for nurses to become familiar with any such systems being used in their workplace. An issue of concern in the use of computer technology is the potential threat to the privacy of the client. Policies and procedures in relation to client health information need to be in place and adhered to by nurses to protect individual rights to privacy and confidentiality. Further information on computers in nursing is covered in Chapter 25.

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