From the earliest beginnings of the nursing profession, nurses have carefully recorded their observations of patients and their interventions to help patients recover from illness and achieve optimal health. Although documentation has always been an important part of nursing practice, today’s increasingly complex healthcare environment and the diversity of settings in which patients receive care require that nurses pay more attention to documentation. The computerized patient record has become standard practice, and the days of repetitive task-oriented narrative notes will soon be part of nursing history. Your patient care documentation will need to be brief, accurate, and focused on your patient’s status and progress toward specific clinical outcomes.

Many people depend on your patient care documentation. Your nursing colleagues and other health care team members make clinical decisions based on your charting. Representatives of regulatory and accrediting agencies look to your charting to make critical decisions regarding reimbursement, licensing, and accreditation. Although documentation formats have evolved dramatically from simple handwritten notes to sophisticated nursing information systems, the purpose of documentation remains constant: to provide a written record of the care a patient receives and the patient’s response to care and medical interventions in a clear, concise, and accurate manner. From protecting your patient to safeguarding your nursing license, to know documentation principles and apply them in daily practice is a must for every nurse.

Chapter 1: Documentation Fundamentals

Why documentation is important

In the 19th century and the first part of the 20th century, nurses recorded their observations of patients under the direction of physicians. Nursing documentation began as a checklist of simple observations, such as whether the patient ate or slept well. The chief purpose for traditional documentation was to record that physicians’ orders had been followed and that a healthcare facility’s policies had been observed.¹

Nineteenth century British nurse Florence Nightingale is regarded as the founder of nursing documentation. In her book Notes on Nursing, she stressed the importance of gathering patient information in a clear, concise, and organized manner.² As nursing achieved professional status, nurses’ observations about patient care and written details of interventions gained increasing relevance and credibility. In the 1970s, nurses began to create their own vocabulary for documentation based on nursing diagnoses.¹

No matter where you care for your patients or what your nursing specialty is, documentation is one of the most critical skills you perform. High-quality documentation is at the core of nursing practice.3 Accurate, detailed charting shows the extent and quality of care that you provide, the outcome of that care, and the treatment and education that the patient still needs.^2,4,5 Keep in mind that what you chart today may be read in the future by many people, including other team members who care for the patient; accreditation, certification, and licensing organizations; performance improvement committee members; the Centers for Medicare and Medicaid Services; and private insurance company reviewers. Your charting may also be reviewed by lawyers or by a judge in the event that your patient’s medical record is part of a legal action.^6,7 In today’s complex healthcare settings, where care takes place in a variety of hospital and community settings, effective documentation is more important than ever.⁷ Table 1 shows some of the reasons for documentation.

Effective documentation provides a picture of the care a patient receives, his or her response to care, and any need for further treatment.² To provide a record of the quality of care a patient receives, you must describe the care you gave and provide evidence that it was necessary. You should also document the patient’s response to care and any changes needed in the nursing plan of care. To assess the quality of your charting, ask yourself: If I were the next nurse responsible for this patient’s care, would these notes allow me to make good nursing decisions?³

Coordination of care — One of the most important objectives for documentation is to communicate the patient’s status and progress or lack of progress to other healthcare professionals.⁸ To plan effective interventions and evaluate a patient’s progress, team members need all the information on a patient’s care. Accurate nursing documentation is an important factor in care coordination because it helps other team members provide more effective care.²

Table 1

Accreditation and licensing — Organizations such as The Joint Commission certify that healthcare organizations meet specific standards to provide health care. Through the accreditation process, healthcare organizations validate their eligibility for government reimbursement and demonstrate to their consumers that they provide quality care. To assess whether a facility should receive accreditation, The Joint Commission reviewers determine how the organization is structured and how it functions. This determination may include patient and staff interviews, along with a review of medical records to determine whether the organization meets the accreditation standards. Accrediting agencies also survey records to ensure the standard of care is consistent throughout the facility. For example, a woman who is recovering from anesthesia after a cesarean birth should receive the same monitoring in the labor and delivery suite as she would in the postanesthesia care unit.² Most accrediting organizations require that each patient’s clinical record contain an assessment, a plan of care, medical orders, progress notes, and a discharge summary.² Some states also require all healthcare facilities, including home health care facilities, be licensed. Licensure reviews include an assessment of the quality and appropriateness of patient care, as demonstrated through a review of documentation.²

Performance improvement activities —Performance improvement activities are mandated by state and Joint Commission  regulations. Members of performance improvement committees monitor and evaluate patient care, and seek ways to improve patient care quality. Committee members develop indicators of quality care to assess the structure, processes, and outcomes of patient care. The medical record can be used to measure quality indicators and to plan corrective action when necessary.^1,7

Peer review — Quality improvement organizations (QIOs) rely on the patient’s medical record to evaluate the quality of care in healthcare facilities. Reviewers evaluate samples of a facility’s patient records to determine whether certain processes are in place, such as those that minimize the need for unscheduled returns to the operating room or ensure adequate and appropriate discharge planning. QIOs operate under the auspices of the Centers for Medicare and Medicare Services.⁷

Requirements for reimbursement — Nursing documentation directly affects the amount of reimbursement a healthcare facility receives for patient care services. The federal government uses a prospective payment system based on diagnosis related groups (DRGs) to allocate reimbursement for patients covered under the national Medicare program.⁶ For a healthcare facility to receive payment, the patient’s medical record must contain the correct DRG codes and must demonstrate that the patient received care in the appropriate setting. Many insurance companies also base their payments on a prospective payment system; they look at medical records to determine the appropriate reimbursement for services provided. Your documentation is key to reimbursement when it verifies and justifies your actions to provide care.^1,2,7

Legal protection — Good documentation should protect you, your patient, other caregivers, and the health care facility where care is provided. Admissible in court as a legal document, the medical record demonstrates the type of care a patient receives.^1,2,4 Medical records are often evidence in disability, personal injury, mental competency, and malpractice cases.^1,2,5 Remember that what you document – or don’t document – can mean the difference between whether a court case is won or lost for you and your employer. Effective ways to protect yourself and your employer legally are to make sure you document your adherence to professional standards of nursing care, following your employer’s documentation policies and procedures, and document carefully in high-risk situations.⁷

Research and continuing education — Researchers who study certain types of patient care phenomena also examine nursing documentation. For example, clinical records can provide data for a study to look at complications associated with a specific intervention or to assess the effects of patient teaching on compliance.³

Clinical record components

Although each healthcare organization has its own clinical record system, a patient’s medical record contains some generic forms that are used throughout the healthcare industry. Table 2 shows the components that comprise a typical patient record for an acute hospital stay.

Table 2

< sectionheader >New ways to plan care

Because The Joint Commission has concluded that the traditional care plan doesn’t necessarily affect patient outcomes, a formal written plan of care is no longer required.1 Several new types of tools for care plans are available, including standardized plans of care, clinical pathways, and patient-outcome time lines.^1,6 Standardized plans of care are concise plans that correspond with a DRG or other descriptors of a patient’s health care status. Clinical pathways – also known as critical pathways, care maps, or care tracks – integrate the principles of case management into documentation. Clinical pathways incorporate multidisciplinary diagnoses and interventions, including nursing and medical interventions, and key events that must occur for the patient to be discharged by a specific date.² A clinical pathway is usually organized by categories based on the patient’s diagnosis; it projects his or her expected length of stay, specifies daily care guidelines, and forecasts expected outcomes. For example, the clinical pathway for a patient who is one day postoperative after a colon resection would focus on nasogastric tube maintenance, intake and output, vital signs, urinary catheter care, incentive spirometry, use of antiembolism stockings and ankle exercises, ambulation, IV site care, wound care, mouth care, safety measures, and bed positioning. The nurse records whether the patient’s progress follows that outlined in the clinical pathway when he or she documents “no variance” from the standard or documents reasons for a variance if one occurs.¹ A patient-outcome time line is another recent documentation tool that allows all members of the healthcare team to note essential diagnostic tests, interventions, patient outcomes, and other parameters to attain the average length of stay for each DRG. For example, the patient-outcome time line for the patient with a colon resection might predict that the patient be out of bed and sit in a chair the day after surgery and walk in the hallway by the third or fourth postoperative day. The time line also lists key interventions to achieve the expected outcomes that monitor the patient’s progress during each shift.¹

Nursing process and documentation

Whatever charting format you use, your documentation must reflect the nursing process.^2,6,7 The nursing process is based on a scientific approach that systematically organizes nursing activities to provide the highest quality of care.² The five-step nursing process ensures compliance with care requirements mandated in both acute and long-term care settings. The importance of the nursing process to provide and document care is also evident throughout Joint Commission standards.^1,2 Table 3 displays the five steps of the nursing process and shows related documentation tools in italics.

Table 3

The first part of the nursing process, assessment, starts when you meet the patient for the first time and continues throughout your relationship as you obtain information about his or her changing condition.^1,6,7 The initial step of the nursing process includes the collection and analysis of relevant information from the patient and other sources as a basis for planning care. The Joint Commission requires healthcare facilities to perform an initial patient assessment for their specific patient population.^1,6,7 Document patient assessments as often as your facility requires, and more often when you observe a change in the patient’s condition. Joint Commission standards require that each patient’s initial assessment addresses the patient’s physical, psychological, and social status. Physical factors include relevant physical findings from the initial physical assessment. Psychological factors include the patient’s concerns about his or her healthcare status. Social status factors may include family structure and the patient’s role in the family, in addition to the patient’s occupation, income level, and socioeconomic factors as they relate to his or her illness. Other important areas for assessment include the patient’s nutritional status, functional status, learning needs, and discharge planning needs.¹ The Joint Commission also requires health care facilities to establish policies on the frequency of patient reassessment. You should reassess your patients and document your findings at least as often as required by your facility’s policies.^2,7

To move to the second step of the nursing process, nursing diagnosis, you must evaluate the patient’s assessment data; look for actual or potential health problems. A nursing diagnosis has three components: the human response or problem, related factors, and signs and symptoms.¹ The human response or problem refers to an actual or potential problem that nursing care can affect positively.¹ Related factors are phenomena that may precede, contribute to, or be associated with the human response. Signs and symptoms, also referred to as defining characteristics, are related to the nursing diagnosis.

After you formulate a nursing diagnosis, you need to plan relevant expected outcomes, goals that your patient should reach as a result of nursing interventions.¹ An outcome can include either an expected improvement in the patient’s functional abilities, such as an increase in walking endurance, or the full or partial resolution of a problem, such as a decrease in pain.¹

An effective plan of care is the basis for effective and meaningful documentation.¹ The plan includes patient problems identified during assessment; realistic, measurable expected outcomes and dates; and nursing interventions that will help the patient and  family achieve desired outcomes. Evaluation, the final step in the nursing process, documents the effectiveness of treatment interventions and proposes changes in the plan of care if necessary.

Discharge instructions

Hospitals discharge patients earlier than they did in the past. As a result, the patient, his or her family, or other caregivers often perform healthcare activities in the home that have traditionally been done by nurses before patients leave the hospital. These activities may include wound healing assessments, dressing changes, tube feedings, and medication administration. Patients and home caregivers may also have to ensure an appropriate diet and activity level and learn how to operate medical equipment.²

To fulfill these responsibilities, the patient and home caregiver must receive adequate instruction. If a patient doesn’t receive appropriate instruction, you may be liable for any injuries caused by inappropriate or inadequate instructions. Many hospitals distribute printed instruction that describe treatments and other home care procedures. Indicate in your documentation which materials were provided and to whom.^5,6 Some facilities combine discharge summaries and patient instructions in one form. Table 4 shows information that should be in discharge instructions.

Table 4

 Documentation guidelines

Document accurately and objectively. Record only what you see, hear, touch, or smell. When you record a patient’s statement, chart his or her exact words in quotes whenever possible. Remember to document only data you witness or data from a reliable source, such as the patient or another nurse. When you include information reported by someone else, name your source.^2,4 Be sure to chart exact measurements and distances. For example, charting that a patient can walk to one end of the hallway and back won’t be meaningful for a home health nurse trying to evaluate a patient’s endurance level. Instead, chart the actual distance in feet or yards. When documenting quantities, avoid generalizations such as a “small emesis” or “voided a large amount.” Exact measurements in size or amount may be critical. Be precise about what you observe. For example, writing “Patient’s incision appears to be healing” is much less specific than “Wound on abdomen measures 12 cm x 6 cm. Pink granulation tissue at wound edges. All sutures intact, with no drainage noted.” When you describe a patient’s pain intensity, describe the pain on a numerical pain scale, such as “Patient reports pain as 8/10, with score of 10 being worst ever” rather than charting “Patient reports severe pain.”¹¹ Avoid terms that don’t give the reader an accurate picture, such as “voided qs,” “ate well,” or “bowel sounds normal.” Effective charting should read “Voided 400 ml clear yellow urine in urinal,” “Patent ate 80% of dinner meal,” and “Abdomen flat and flaccid; rumbling noises heard on auscultation.”

Get the facts about a situation before charting and don’t make assumptions about an event.^4,6 For example, don’t chart that a patient pulled out his IV line unless you or another staff member saw him do it. Instead, document your findings: “Found patient’s IV line and venipuncture device untapped and hanging free. Arm board and bed linens covered with blood.”⁷ Avoid terms that are ambiguous or subjective. For example, charting that a patient “requests pain medication periodically” doesn’t communicate much. Instead, describe the time intervals between requests for pain medication specifically. Don’t use vague terms, such as “seems” or “appears.” These terms may imply that you aren’t certain about your observations.^2,7 Avoid subjective references to a patient’s behavior such as “Patient seems frustrated” or “Appears anxious.” Instead, paint a picture of the behavior: “Patient voiced frustration about inability to self-inject insulin” or “Patient repeatedly rings call light to ask about results of lab tests.” Rather than charting a vague statement such as “Patient reports good relief from pain medication,” provide clearer detail by charting “Patient states incisional pain is decreasing – describes pain now as a 2 on a 1-to-10 scale.”

Document clearly and thoroughly. Avoid using long or complex words when short simple words will be more effective. Don’t be afraid to use the pronoun “I,” as in “I contacted Dr. Bryant at 1115 and reported the following facts…”¹ Be sure to chart all relevant information about a patient’s care. In court, you’ll find it difficult to prove you provided an aspect of patient care if you haven’t documented it. For optimum legal protection, describe in detail actual or potential problems, nursing actions you took to resolve them, and the patient’s response to your actions. Chart specific information about implementing safety precautions and attempts to contact the patient’s physician.

Note times carefully. Be specific when you record the exact times of observations and events, particularly any changes in the patient’s condition or significant events and nursing actions.^2,6,7 Don’t use block charting that covers a wide range of time, such as “7 AM to 3 PM.” This time range sounds vague and implies inattention to the patient.^2,6,7 Try to document pertinent information as soon as possible after an event. That way, you won’t be as likely to forget important details, and your charting will be more accurate. In addition, if you become involved in litigation, you’ll find it easier to defend your actions because prompt charting leaves no question about when an event occurred. If you can’t document at once, note the time when you do chart – explain the delay, such as “no access to patient’s chart temporarily, “and note the time the event occurred. Record the exact time something happens: If a patient has an emesis at 1:15 p.m., chart that time, not “approximately 1 PM” – noting the precise time of a significant event or complaint and your response to it may be crucial, especially in a court of law.²

Avoid assigning blame or calling attention to errors. Staff conflicts about patient care are legitimate but don’t belong in a medical record. For example, when you question a physician’s treatment decisions or criticize a colleague’s performance or care given by others, it reflects poorly on all members of the team. In a court of law, accusations in the chart can be used to show that the patient received incompetent or substandard care.⁴ Report any criticism of your care by another nurse in the chart to your supervisor. Don’t respond to the criticism in the chart, and don’t alter the chart in any way. If you question another nurse’s care, objectively report your findings in an incident report. Without blame, describe what you assessed or witnessed, your interventions to protect the patient, and the names of your supervisor and the patient’s physician and the times you notified them.⁵

Avoid using terms associated with errors, such as “accidentally,” “by mistake,” “somehow,” “miscalculated,” and “unintentionally.”¹ These words can be interpreted as admissions of errors in patient care. Instead, document the facts: “Patient given 10 mg morphine sulfate IM for incisional pain at 0830. Dr. Green notified at 0845. No orders received.”1 Don’t chart that a piece of equipment isn’t available. Instead, document a clear picture of the facts: “Blood transfusion via a regular pump on the recommendation of the laboratory (or physician order)” — then, fill out an incident report that states no blood warmers were available, what you did, and why.⁹ Don’t write, “No blood warmers available” in the patient’s medical record.

Fill out forms correctly, write in ink, and sign each entry. Don’t leave blank spaces in the progress notes or on flow sheets – a blank space may imply omission of a potentially important task, such as the completion of a procedure or a full patient assessment.

Blank spaces in progress notes also allow others to add information to your notes.^2,7 Because the medical record is a permanent document, use black or blue ink when you fill it out or print it from a computer.^1,6

Use standard abbreviations. Use only abbreviations approved by your facility. Most facilities encourage use of metric rather than apothecary symbols, such as fluidounce, fluidram, and minim, which can be misinterpreted.^1,2

For drug names, use generic rather than trade names and spell out drug names. For example, avoid a term such as “MTX” for the drug methotrexate, “CPZ” for compazine, “dig” for digoxin or digitoxin, or “HCTZ” for hydrochlorothiazide.¹ Dosage directions like “QD,” for once daily, can be confused with “OD,” the abbreviation for right eye. OJ for orange juice may be interpreted as OD or OS. There have been situations in which medications that were meant to be diluted in orange juice and given orally were instilled into a patient’s right or left eye.¹ To avoid misinterpretation, write abbreviations out. New patient safety goals from The Joint Commission address these issues.

Write legibly and spell correctly. A person who reviews a chart with sloppy writing and poor grammar and spelling may conclude that the care given was unprofessional.^1,2 Be sure to write neatly and use correct grammar and spelling. It is helpful to keep a dictionary in charting areas for staff reference and to post a list of commonly misspelled words, especially common terms and medications on your unit.^1,6 Illegible handwriting frustrates other healthcare professionals; they may waste valuable time to decipher it. A patient may even be injured if other caregivers can’t read vital information.¹

Correct errors and omissions. When you make a charting error or omission, correct it as soon as possible following your facility policy. Never erase, cover, write over, or make an entry unreadable.^2,4,7

If the chart is reviewed in a legal action, the patient’s attorney will look for any evidence that may imply the patient’s chart is inaccurate. A chart that has erasures, correction fluid, or heavy black ink to make an entry unreadable are red flags.⁶

Cosign correctly. Review and follow carefully the policy at your facility for countersigning chart entries. Although countersigning doesn’t indicate that you personally performed a procedure, it does imply that you reviewed the entry and approved the care given.⁵

Use caution when you countersign a subordinate’s chart entries. Review each entry and make sure it clearly identifies who did any procedure or provided care. If you develop a practice of automatically countersigning without reviewing an entry or if you overlook a problem that the entry raises, you could be liable for any patient injury that results.

Don’t document care given by someone else.⁴ Unless stated otherwise in the chart, any person who reads notes with your signature assumes that they are a firsthand account of observations made and care provided.

In some facilities, unlicensed assistive personnel, including nursing assistants and technicians, are prohibited from making formal charting entries. If this is the policy in your facility, your documentation must reflect that you assessed the patient and evaluated the care you assigned to a subordinate staff member.²

Follow correct procedures for late documentation. You may need to make a late entry to a patient’s chart when the patient’s chart is unavailable, or when you need to add important information after you have already finished documenting. To avoid any implication that you’ve altered a medical record, be sure to follow your facility’s policies and procedures when you make a late entry. Often, the policy is to add your entry to the line in the progress notes available and write “late entry” to indicate that the entry is out of chronological sequence. Then, record the time and date of the late entry and, in the body of the entry, record the time and date of the care.

Chapter 2: Different Formats, Different Settings

The type of facility and the setting in which you work will determine the different documentation formats you may encounter. Each documentation system has its strengths and limitations. Joint Commission standards that emphasize outcomes of care and state and federal regulations should drive the selection of a documentation system. The goal is to implement a system that demonstrates the essence of nursing care, supports an interdisciplinary approach, and focuses on patient outcomes.^1,2,3 Follow your facility’s and your state nurse practice act’s requirements for documentation.

Documentation formats

Narrative or source-oriented charting

The traditional method of documentation in acute care is known as source-oriented or narrative charting. For this type of charting, members of each discipline — the sources — chart patient information in separate sections of the medical record. Narrative charting is a straightforward,^1,2,4 chronological account of the patient’s status, nursing interventions, and the patient’s response to interventions. Narrative charting is usually written on progress notes and supplemented with various types of flow sheets.^2,4 Although narrative charting is simple, it is time-consuming, it may contain numerous duplications, and it often results in an unorganized record that makes it difficult to determine a patient’s progress quickly.² It may also make it difficult for team members to obtain a clear and comprehensive report of the patient’s care and may cause communication barriers. Collaboration is easier when team members who use narrative charting document on the same progress notes.² Focus charting and PIE (problem, intervention, evaluation) charting, which will be discussed later in this section, have evolved from traditional narrative documentation.

Problem-oriented charting

Problem-oriented charting was introduced as an alternative to the traditional source-oriented or narrative charting format.¹ Many healthcare facilities have converted in whole or part to problem-oriented charting to document patient care. Table 5 shows components of problem-oriented charting.

Table 5

The patient database contains subjective and objective data about the patient from all disciplines as part of the initial assessment. The database includes information such as the reason for admission and the patient’s medical history, allergies, medications, physical and psychosocial assessment findings, self-care abilities, learning needs, and discharge planning issues.^1,3,5 The problem list is a numbered list of health problems written in chronological order as each problem is identified.^1,2,5 Problems are referred to by number in progress notes. The problem list, which serves as an index for the medical record, is placed at the front of the record where it can be seen quickly by members of all disciplines. Problem names may include medical diagnoses such as “congestive heart failure” and nursing diagnoses such as “activity intolerance.” When a problem is resolved, the time and date are noted, and further documentation on the problem ceases.

The initial plan of care is based on the patient problems identified during the first assessment. The plan for each problem includes care goals or outcomes, treatment plans, and patient education plans.5 Involve the patient and his or her significant other in the planning process. Progress notes, written in a format called SOAP,^1,2,3 monitor changes in the patient’s condition and response to treatment. Components of problem-oriented documentation are:

S:          Subjective information

O:          Objective information

A:          Assessment

P:          Plan

“S” is the subjective information the patient provides, such as why he or she seeks care, or statements of symptoms or concerns. Subjective data can also come from family members or significant others. The “O” is for objective information, such as observable signs and symptoms, vital signs, or the results of laboratory tests or other diagnostic information. “A” is for assessment. Under the assessment heading, document your conclusions, formulated as patient problems or nursing diagnoses, based on both subjective and objective data. “P” stands for plan; the interventions you intend to use to resolve the problem, including short-term and long-term goals.⁶ Progress notes are generally written for each problem every 24 hours or when the patient’s condition changes.

Some facilities use a SOAPIE or SOAPIER format to add the categories interventions, evaluation, and revisions. “I” details the specific interventions to resolve the problem, “E” focuses on your evaluation of the patient’s response to interventions. “R” is for revisions to the plan based on an evaluation of the effectiveness of the treatment plan.⁴ The discharge summary addresses each problem on the list and notes whether the problem was resolved. Document plans for any unresolved problems after discharge in the discharge summary, along with pertinent communications with other healthcare providers, such as home health agencies.

The major advantage of the POMR (problem-oriented medical record) system is better communication among health care team members. Any team member can readily find the patient’s problems at the front of the record, obtain a status report from a single progress note, and easily find specific information in well-organized progress notes.^1,4

There are also some disadvantages to the POMR system because of its emphasis on documenting problems chronologically rather than in their order of priority. POMR also isn’t suited for settings with rapid patient turnover.⁶

Focus charting

Focus charting, an adaptation to narrative charting, lists pertinent patient information (or the focus of concern) by key words in a column on a progress sheet.^1,2,3 The key words may be a sign or symptom, such as pain or dyspnea; a nursing diagnosis, such as potential for skin breakdown or ineffective airway clearance; a behavior; a condition; a significant event; or an acute change in the patient’s condition. In the next column, notes are organized by data, action, and response or DAR framework. “D” refers to the data gathered from the patient assessment; “A” refers to the actions you take based on assessment data, and “R” describes the patient’s response. Routine nursing tasks and assessment data can be documented on flow sheets and checklists.^2,4

PIE charting

The PIE system organizes information by patient problems.^4,5,6 This system requires the completion of a daily assessment flow sheet and progress notes. Integration of the care plan into the nurses’ progress notes eliminates the need for a separate care plan and provides a record with a nursing, rather than a medical focus.^3,4,5 Data are collected from the initial nursing assessment to formulate relevant nursing diagnoses. For PIE charting, each documentation entry is divided into three components: the problem, written as a nursing diagnosis (P); interventions (I), states the nursing actions to resolve the problem; and (E), evaluation, determines the success of the nursing interventions. A variation of this format, APIE, includes an assessment component, labeled “A.” PIE charting is a logical and easy-to-use format; however, to find all the nursing actions performed for each problem, you must read documentation from several shifts.^1,2

When you document a problem, label it as “P” and assign the problem a number, such as P #1 in the progress notes. Next, document the nursing interventions to address each problem or nursing diagnosis. Label each entry as “I” followed by “P” and the problem number, such as IP #1. To document your evaluation of the patient’s response to treatment, use the letter “E,” followed by “P,” and the problem number, such as EP #1.^1,2

Charting by exception

The charting by exception (CBE) format differs significantly from traditional systems as it restricts documentation to only significant or abnormal findings in the narrative portion of the record.^1,4 To use CBE documentation effectively, you must know and adhere to established guidelines for nursing assessments and interventions and follow written standards of practice. You document only significant findings or exceptions to certain norms that are based on clearly defined standards of practice and predetermined criteria for nursing assessments and interventions. Explanations for deviations from the norm are on progress notes. To supplement these notes, there are specially designed flow sheets for physical assessments and interventions documentation. Because the CBE system streamlines documentation, it saves time, a major advantage.² It is also easy to find issues that affect patient outcomes with the CBE system.

The CBE format involves the types of forms below:⁵

• A nursing diagnosis-based standardized care plan. For each nursing diagnosis identified, the nurse uses a preprinted plan of care for that nursing diagnosis and personalizes the care in the blank spaces provided.

• Nursing care flow sheets to document assessments and interventions. These flow sheets, usually designed to cover 24 hours, compare findings with normal parameters and with previous nurses notes to determine whether the patient’s condition has changed. If there is no change, the nurse checks the box and adds her or his initials. If findings aren’t within normal limits or don’t match the previous assessment, place an asterisk in the box and chart assessment findings about the abnormality or change in a comments section or some other designated area such as progress notes.

• A graphic record to document trends in vital signs, weight, intake and output, and activity level. As with the nursing care flow sheet, use check marks and initials to indicate expected findings and asterisks to indicate abnormal findings; then chart a description of the abnormality or deviation.

•  A patient teaching record. This record tracks and documents patient and family teaching and outcomes of teaching.

• A patient discharge note to document discharge planning. A typical discharge form includes sections to document patient instructions, appointments for follow-up care, medication and diet instructions, signs and symptoms to report, level of activity, and patient education.

• Progress notes to document revisions to the plan of care. These notes document interventions that don’t lend themselves to any of the flow sheets.

Because minimizing documentation may increase legal risk, well-designed flow sheets are crucial in a CBE system. However, you may need to supplement your CBE documentation with nurses’ progress notes.^5,6 For example, in a situation in which CBE doesn’t provide a clear, accurate description of a patient’s condition, you’ll need to write it in a narrative note. As it may be several years before a lawsuit is filed, CBE makes it difficult for nurses to demonstrate they provided appropriate care, especially when patients develop complications. Although CBE saves charting time, legal experts advise hospitals to develop their CBE systems carefully and to implement quality-control measures to ensure the systems are used appropriately.⁷

FACT charting

The FACT (flow sheets, assessment, concise progress notes, treatment) documentation system incorporates many CBE principles; the nurse documents only exceptions to what is normally expected or significant patient information.^2,5 The FACT system contains flow sheets, assessments with baseline parameters, and concise progress notes that document the patient’s condition and response to treatment.^2,5

Core charting

Core charting focuses on the core of documentation: the nursing process. Core charting consists of a database, a care plan, flow sheets, progress notes, and a discharge summary. The database is used as the initial assessment and focuses on the patient’s body systems and ability to perform ADLs. The care plan includes a summary of the patient’s problems and relevant nursing diagnoses. Flow sheets chart the patient’s activities and responses to nursing interventions, patient teaching, and diagnostic procedures.^4,5 A DAR (data, action, and response) format is used for documenting in the progress notes.

Documentation in different settings

Acute care documentation

In an acute or critical care setting, nurses record assessment findings, nursing interventions, patient responses, and patient outcomes.^1,2,8 Much of critical care documentation is entered on flow sheets accompanied by commentary and critical data, such as an ECG strip.^1,2 The nursing admission assessment form contains relevant physiologic, psychosocial, and cultural information, and describes subjective and objective data about the patient’s health care status and actual and potential problems. The admission assessment form also provides information about the patient’s ability to comply with therapy, his or her expectations for treatment, and family relationships and dynamics — psychosocial information needed to plan effective nursing care.^1,2

Progress notes describe patient problems and needs, pertinent nursing observations, nursing reassessment and interventions, patient responses to interventions, and progress to meet expected outcomes.^1,2,8 Patient care Kardexes are forms that provide a quick overview of basic patient care information, often referred to during change-of-shift reports and throughout the shift.^1,2 A Kardex usually contains information from the medical record face sheet, such as the patient’s name, age, marital status, religion, allergies, together with medical and nursing diagnosis, physician’s orders for medications, treatments, diet, IV therapy, diagnostic tests, scheduled procedures, advance directive status, permitted activities, functional limitations, assistance needed, safety precautions, and an emergency contact name and telephone number.^1,2

Graphic forms are used for around-the-clock assessments. These forms track various changes in quantitative data, such as vital signs, weight, intake and output. Flow sheets provide an easy-to-read description of changes in a patient’s condition. A clinical pathway is often used in acute care to outline the standard of care and specify expected activities related to the patient’s diagnosis.^1,2 Patient and family teaching forms provide evidence that the healthcare team has implemented a teaching plan and evaluated the effectiveness of the plan. These are often preprinted forms for a specific diagnosis that can be customized for each patient’s unique situation. Discharge summary and patient instruction forms document assessment of a patient’s continuing care needs and referral for care. Many healthcare facilities combine discharge summaries and patient instructions in one form.

Long-term care documentation

Although documenting in acute care and long-term care settings is similar, documenting in long-term care settings differs in two important ways.⁸ First, documentation isn’t done as often as in an acute care setting because changes in patients’ conditions are not expected to occur frequently and patients stay longer, often for weeks or months. Second, long-term care facilities are highly regulated by state and federal agencies, and strict documentation standards are required;² a comprehensive view of the patient’s needs is documented on forms that are often lengthy and complex.^2,8

State laws and Medicare’s conditions of participation determine to a large extent what to record in long-term care. The Centers for Medicare and Medical Services  ensures compliance for government-paid services under the Medicare/Medicaid program. Medicare provides limited reimbursement for services provided in long-term care facilities, except for services that require skilled care, such as IV therapy, parenteral nutrition, respiratory care, mechanical ventilation, and physical, occupational, and speech therapy.^6,8 To reimburse long-term care facilities for these services, Medicare guidelines require that documentation clearly shows that the patient requires care by professional or technical staff members. When patients don’t improve or aren’t expected to benefit from rehabilitation, they become ineligible for Medicare coverage.8 Nursing documentation is vital to provide such evidence.

Not all patients in long-term care facilities are elderly. Patients under age 65 who need skilled care must pay for care themselves or, if they are eligible, may receive reimbursement through the federal Medicaid program. To receive Medicaid reimbursement, documentation must reflect Medicaid standards.^5,6 The Omnibus Budget Reconciliation Act requires the completion of a comprehensive assessment known as a “minimum data set for resident assessment and care screening,” or MDS, within a specific time frame of the patient’s admission to a long-term care facility.⁶ The MDS must be also be reviewed and repeated at specified time frames.⁶

The quality of nursing documentation in long-term care settings is critical for appropriate reimbursement.^2,8 To qualify for reimbursement, patient records must clearly reflect the level of care the patient receives. For example, if you provide care for a patient with a pressure ulcer, Medicare requires documentation that describes daily activity; skin condition; turning and positioning measures; the ulcer’s size, site, and degree of healing; the patient’s nutritional status; and any other relevant factors.⁵

Documentation in home care

The development of a prospective payment system (PPS) for home health care, use of the outcome and assessment information set (OASIS) as a documentation tool, an increase of elderly patients, and the availability of sophisticated home care equipment are trends that have spurred significant growth in home health care services.² As with acute and long-term care, state and federal law and agencies regulate home health care agencies.⁸ Nursing services provided in a patient’s home range from caretaking and assistance with basic ADLs to highly complex and advanced interventions such as IV therapy via central and peripheral lines, mechanical ventilation, and chemotherapy. In no other health care setting is the nurse as responsible to ensure reimbursement as in home health.⁹ The ability to receive appropriate reimbursement for services depends on the nurse’s documentation skills. For this reason, home healthcare organizations have a highly structured documentation system. Medicare’s conditions of participation strongly influence the documentation required. Table 6 outlines criteria for a patient to receive Medicare reimbursement for home healthcare services.

Table 6

To increase efficiency and to meet licensing, accreditation, and reimbursement requirements, most home healthcare agencies use visit sheets and physical discomfort forms for each p