Charting and Documentation in Healthcare

• Record clearly and thoroughly.
• Ensure measurements and numbers are precise.
• Avoid third-person pronouns like "he," "she," and "they."
• Document time using a 24-hour clock to accurately reflect care.
• Use terminology and abbreviations approved by your employer.

Charting - Electronic

• Healthcare workers in rural/remote areas can send client health data electronically to practitioners, doctors, or team members far away.
• Electronic health records are easily readable, facilitate quick responses, and bridge care access gaps.
• See Box 26-6: Guidelines for Electronic Documentation (p. 584).

Method of Charting: Progress Notes

• SOAP is a common method of charting progress notes.
• SOAP includes the following:
  • Subjective Data
  • Objective Data
  • Assessment
  • Plan

Documentation

• Methods of documentation include SOAP, DAR, and ADPIE.
• Identify ways of documentation.
• Utilize systematic documentation system
• Understand how to complete Transfer of Accountability
• ISBAR is a way to understand how to complete Transfer of Accountability

Documentation (definition)

• Documentation serves as legal documents and client records.
• Documentation serves as a written account of a client's condition, illness, care provided, and responses to that care.
• Documentation acts as a permanent legal record for healthcare team communication.
• Most documentation is electronic, but paper-based systems persist in some agencies.
• Communication provides continuity of care using data about past health issues to identify patterns/changes.
• Accountability is ensured through documentation that is signed, dated, and completed by the individual providing care.
• Legislative requirements must be met.
• Quality improvement and assurance are components of proper documentation.
• Research can be done using documentation.
• Funding and resource management rely on documentation.
• The record/chart has multiple forms depending on the facility.

Methods of Charting Progress Notes

• PIE charting method includes the following:
  • Problem
  • Intervention
  • Evaluation

Example of PIE Charting

• Problem: Client unable to tolerate activity of walking down the hallway, becomes short of breath, and needs to take breaks.
• Intervention: Discuss with team and client alternative physical activities that do not require walking, and discuss need for alternate mobility devices like scooter or wheelchair.
• Evaluation: Client receptive of alternate mobility devices and physiotherapist will develop activity plan.

Methods of Charting Progress Notes

• ADPIE adds analysis and diagnosis components to PIE:
  • Analysis
  • Diagnosis

Methods of Charting Progress Notes: DARE

• DARE (also known as focused charting) includes:
  • Data
  • Analysis and action
  • Response
  • Evaluation

Examples of DARE Charting

• Data: Client states "I get so frustrated because I can't walk down the hallway," expresses frustration at the inability to walk short distances, uses a walker with frequent breaks for breath, and has a wife present as a support person.
• Analysis and Action: Client wants to remain active and walking but is unable to walk short distances, so the physiotherapist suggested alternative ways to engage the client by involving the physiotherapist and considering a scooter for longer distances.
• Response: Physiotherapist involved the client in chair exercises and recreational activities, and the case manager is investigating getting a scooter. The client is more involved in recreational activities.
• Evaluation: Determine if activities fulfill the client's goals.
• Box 26-9 provides examples of progress notes in different formats (p. 587).

Transfer of Accountability (TOA)

• Handover happens between health professionals.
• Good communication ensures continuity of care.
• Agencies use different methods: taped, verbal, written.
• A Kardex is often used as a guide/tool.
• It's a formal process.
• Communicate objectively, appropriately, and concisely with other health professionals.
• Understand and use medical/nursing terminology.
• Interpret charts and other documents.
• Write up patient observations.
• Understand clinical procedures.

TOA - Tips

• Be organized
• Follow a structured sequence when handing over patient details, presenting complaint, history, treatment, and care plan.
• Include clinical observations, pathology results, procedures, and don't forget to highlight allergies, relevant patient history, and medical conditions.
• Be prepared to go back or forward to help colleagues follow the information; what is the care plan for the next shift?
• Stay focused.
• Stay relevant.

Documents Used in Charts

• Data forms, used in LTC (long-term care), detail physical, emotional, social, and cognitive health, plus activities, interests, medications, treatments, and therapies.
• Data forms are sometimes called assessment forms (p. 580).
• Assessment forms (case managers use) help identify problem areas.
• Home assessment forms document changes needed to adapt a client's home during rehabilitation.
• Care plans (by nursing and other disciplines) contain goals and interventions from assessments.
• Other flow sheets record frequent measurements and observations - BP every 15 minutes on a vitals signs flowsheet (p. 581).
• Summary reports are monthly or bi/tri-monthly summaries of a client's condition/services used in the community/LTC.
• Progress (RN) or Narrative Notes (PSW): Vary by discipline but document client care including assessment, dx, planning/goals, implementation, and evaluation (p. 581).
• Graphic sheets are used to record measurements and observations made on every shift, such as vital signs, height, weight, and I & O.
• ADL checklists and flow sheets, sometimes called tick sheets/task sheets, are used by community agencies to record care/services for a 24-hour period (written/electronic IPad) (p. 583).
• Incident reports are written accounts made after an accident, error, or unexpected event.
• Kardex is a card file summarizing client information that is updated frequently but rarely used in community settings.
• Health team members record information on forms for their departments.
• Agency policies cover who records, when to record, terminology, abbreviations, and correcting errors.

ISBAR - Identify, Situation, Background, Assessment and Recommendation

• ISBAR is a good communication tool that keeps thoughts organized, and helps gather information before contacting someone.
• I – Introduction: Identify who you are, your role, where you are, and why you are communicating.
• S – Situation: Describe what is happening at the moment.
• B – Background: Detail the issues that led to this situation.
• A – Assessment: State the perceived problem.
• R – Recommendation: Explain what should be done to correct the situation.

Example of Using ISBAR

• Introduction: Memo from Felicity Black, Service Manager, Fenton Mental Health Service, to all staff.
• Situation: For the next two weeks, staff should use the front entrance of the building to enter and leave.
• Background: A new security system is being installed starting Monday, requiring the rear door to be inoperable for five days.
• Assessment: Passage through the rear door will not be possible.
• Recommendation: From Monday morning, please use the front door for entry/exit and advise visitors likewise.