DOCUMENTATION

RECORDS AND REPORTS

PRISCILLA NANCY A. LASERNA, MAN.

Introduction
 Patient’s records serve many purposes such as:
 communication with other healthcare professionals
 recording of therapeutic and diagnostic orders
 care planning
 quality-of-care recording
 research
 decision analysis,
 education,
 legal documentation,
 reimbursement,
 historical documentation
*(Taylor et al. 2005)

Patients’ records help healthcare professional from different disciplines interact

with the patient at different times to communicate with one another. Healthcare
professionals often make judgement about nurses and nursing contribution to the
healthcare team partially on the basis of what is documented on the patients’ records.

Nurses are responsible for ensuring that diagnostic and therapeutic orders are
entered in the patients’ records and implemented. These orders should be written and
signed by the ordering physician.

Data to be recorded in the patient’s chart

 Admission date, time, and room/bed number of patients.

 Mode of admission, such as, ambulatory, by wheelchair, by stretcher, etc.
 Vital signs: Blood Pressure (BP) level of consciousness; Pulse Rate (PR);
Respiratory rate (RR).
 Admission notes, the newer version is focus charting.
 The observed disposition of valuables endorsed for safe keeping.
 The Admitting physicians.
 Written (orders) prescription of physicians.
 Medications given: date, time, dosage, route
 Specimen (s) obtained:
 Type of Specimen (s)
 Time it was obtained
 Time it was submitted to the laboratory with signature who submitted
and received the specimen. This will prevent loss or misplace of
specimen.
 Status of patient during transfer to other patient areas.

In-Patient areas
• Time of doctor’s visit and all subsequent visits of the physician
• Written orders of all physicians
• Specimen (s) obtained:
 Type of specimen (s)
 Time it was obtained
 Time it was sent to the laboratory
 Reactions, attitude, Moods and Status of the patient
 Pertinent subjective observation
 Complaints of pain
 Discomfort of other attitudes
 State of depression; worry, agitation, reaction to
hospitalization or illness.

Objective observation
  General Appearance / Changes on:
 Respiration
 Drainage
 Condition of the skin
 Edema, etc.
 Attitudes / Observation for any signs of:
 Depression
 Worry
 Agitation
 Reaction towards hospitalization or Illness
 Activity / Type of activity
 Nurse’s observation
 Position changes as to time
 Response and tolerance to activity
 Paralysis and degree of limitation of movement.

Vital signs: Time checked and description of

 Pulse rate
 Respiratory rate
 Cardiac rate
 Temperature
 Blood Pressure
 Level of Consciousness
 Body weight and height taker on admission
 Therapy and time instituted
 Medications
 Prescribed diet and appetite of the patient including allergies or idiosyncrasies
 Transfer as to date, time and made to and from any unit or department
 Nursing Care Rendered
 Nursing procedures
 Comfort measures
 Health teachings
 Evaluation of care
 Completion of the day’s charting at midnight as to time, date and
calendar hospital date.
 Use of black / blue ink for AM and PM shifts, red for night shift.
 Accident, such as, patient falling from the bed shall be reported to
the immediate supervisor and recorded indicating the time and the
condition of the patient.
 FOCUS CHARTING
Jason D. Cristobal, RN MAN

Focus charting describes the patients’ perspective and focuses on documenting the
patients’ current status, progress towards goals, and response to interventions.
Purpose
Brings the focus of care back to the patient and the patients’ concerns. Instead of a
problem list or list of nursing and medical diagnosis, a focus columns is used that
incorporates many aspects of patient and patient care.

The focus might be patient strength, problem, or need. Topics that may appear in the
focus column include patients’ concerns and behaviors; therapies and responses; changes
of condition; significant events such as teaching, consultation, monitoring, management
of activities of daily living or assessment of functional health patterns.

The narrative portion of focus charting includes DATA, ACTION, and RESPONSE ( D
A R ). The principal advantage of focus charting is in the holistic emphasis on the patient
and his/her priorities including ease in charting.

 Objectives
 To easily identify critical patient issues / concerns in the progress notes.

 To facilitate communication among all disciples

 To improve time efficiency with documentation.

 To provide concise entries that would not duplicate patient information

already provided on flowsheet / checklist.

 General guidelines
 Focus charting must be evident at least once every shift.
 Focus charting must be patient-oriented not nursing task-oriented.
 Indicate the date and time of entry on the first column.
 Separate the topic words from the body of notes:
Focus note written on the second column.
Data, Action and Response on the third column.

 Sign name (e.g. K. Aquino, RN) for every time entry.

 Document only patient’s concern and/or plan of care e.g. health teachin
per shift, hence, general notes are not allowed.
 Document patient’s status on admission, for every transfer to/from
another unit or discharge.
 Follow the do’s of documentation.
 For eight hours shift, use blue or black ink for morning and
afternoon shift, red ink for night shift.

Specific Guidelines

 Begin with comprehensive assessment of the patient using inspection, palpation,

percussion and auscultation (IPPA).

 Include in the assessment, collection of information from the patient, family,

existing health records (such as checklist / flow sheets, laboratory results and
other health care providers.

 Establish a focus of care, to be addressed in the progress Notes.

 Document the four elements of focus charting, as necessary,

wherein:
  FOCUS identifies the content or purpose of the narrative entry and is
separated from the body of the notes in order to promote easy data
retrieval and communication.
 DATA is the subjective and/or objective information supporting the stated
focus or describing the observation at the time of a significant event.
 ACTION describes the nursing interventions (independent, basic and
perspective) past, present or future.
 RESPONSE describes the patient outcome/response to interventions or
describes how the care plan goals have been attained.

Focus note is necessary

 To describe a patients’ problem/focus/concern from the care plan – when the
purpose of the note is to evaluate progress toward the
defined patient outcome from the plan of care.
Examples: Self care
Skin integrity
Activity tolerance

 To identify an exception to the expected outcome – when the significant finding

or an outcome is not expected (the exception).

Examples: Wheezes left base

Nausea

 To document a new finding – when the purpose of the note is to document a new
sign or symptom or a new behavior which is the current focus of care. (These
may be “temporary foci” which do not need to be incorporated on the plan of care
because they can quickly be resolved. Even if you are uncertain whether the sign
or symptom is important, it is valuables to communicate the information to the
health care team.)

 To document an acute change in patients’ condition – when there has been an

event of new patient condition.
Examples: Respiratory distress
Seizure
Code blue
 To document a significant event or unusual episode in patient care – when (a)
responsibility for patient care changes from one department to another (b) a
significant treatment / intervention took place.
Examples: Admission:
Post- (specify procedure) assessment
Pre-transfer assessment
Discharge planning
Discharge status
Transfusion RBC
Begin thrombolytic therapy
PRN medication required

 To document an activity or treatment that was not carried out – when treatment or
activity in the flow sheet was not provided to the patient or was different from the
standard of care.

 To describe all specific patient / family teaching – this is in compliance with a

standard of care.

 To identify the discipline making the entry as well as the topic of the note – when
all members of the patient care team use one patient programs record.
Examples: Social service / financial assistance
Dietician/instruct low fat diet
Physical therapy/crutch walking
  To best describe patient’s condition in relation to medical
diagnosis – when the patient’s focus is the pathophysiology rather than patient’s
response to the problem. This happens most frequently in highly technical areas
such as critical care.

 Data statements contain objective and/or subjective information.

 Action statement contains only nursing interventions (basic, perspective,

independent) past, present, or future.

 Patient outcome are evident in the response statements.

 Data, Action, Response only contain information related to the focus, none
of the information is extraneous (e.g., asleep, watching TV, visited by
family).

 Response statements are documented after PRN medications are

administered.

 Information from all those categories (Data, Action, Response) should be

used only as they are relevant or available. However, all appropriate
information should be included to ensure complete documentation.

 DATA and ACTION are responded at one hour and RESPONSE is not added until
later, when the patient outcome is evident.

 Examples of Focus Charting:

DATE/TIME FOCUS DATA, ACTION, RESPONSE

10/11/09 Chest pain D: “Sumasakit ang dibdib ko.”
10:00 AM Midclavicuar line pain of 4 on
scale of 5
A: Medicated with Isordil 5mg. SL
Laserna, RN
12:00 NN Chest pain R: resting in bed. “nabawasan na
sakit ng dibdib ko. Rating of 2”
Laserna, RN

 RESPONSE is used alone to indicate a care of plan goal has been accomplished.
Example:

DATE/TIME FOCUS DATA, ACTION, RESPONSE

10/05/09 Health Teaching: R: Patient demonstrated he is
1PM Dressing change able to change his own
dressing using aseptic
technique.
Laserna, RN
 DATA is used when the purpose of the note is to document assessment finding and
there is no flow sheet/checklist for that purpose.
Example:

DATE/TIME FOCUS DATA, ACTION, RESPONSE

10/10/09 Post transfer D: Received from RR via stretcher, awake and
1PM Assesment alert, vital signs stable, IV right forearm ,
foley catheter in place with clear yellow
urine, dressing on RLQ is clean and dry,
moving all extremities voluntarily. “Minimal
incissional pain at this time rating of 3.”
Laserna, RN

 ACTION and RESPONSE are repeated without additional data to show the sequence
of decision making based on evaluating patient response to the initial intervention.
Example:

DATE/TIME FOCUS DATA, ACTION, RESPONSE

10/05/09 Nausea D: “I feel like my stomach is filling up again and
1PM I’m nauseated.” Abdomen around and soft,
gastrostomy bag at body level. Rare bowel
sounds.
A: Gastrostomy bag lowered.
R: “I feel like better now”Approximately 200cc
golden fluid returned as much flatus.
A: Keep gastrostomy bag at body level.
Monitor abdominal status. Monitor how long
bag is tolerated at body level. Document
time and amount of drainage and
discomfort. Patient instructed to call nurse
when he is uncomfortable.
R: “ I understand plan.”
Laserna, RN

 Begin the note with ACTION when the patient’s interaction begins with intervention
or when including date would unnecessary repetition.

DATE/TIME FOCUS DATA, ACTION, RESPONSE

10/10/09 Health Teaching: Digoxin A: Patient instructed on the
2:20 PM actions and side effects of
digoxin. Given digoxin
information card. Discussed
when he would call the
physician about the
medicine.
R: Return demonstration of
radial pulse. “I understand
the purpose of medication.
Laserna, RN
Documentation DO’s and DON’T’s

DO’s DON’T’s

 DO read what other providers  DON’T begin charting until

have written before providing
care and before charting.
 DO time and date all entries.
 DO use flow sheet/checklist
current. DO chart as you make
observations.
 DO write your own
observations and sign over
printed name. Sign and initial
every entry.
 DO describe patient’s
behavior.
 DO use direct patient quotes
when appropriate.
 DO be factual and complete.
Record exactly what happens to
patient and care given.
 DO draw a single line thru an
error
mark this entry as”ERROR” and
sign your name.
 DO use next available line to
chart.
 DO document patient’s current
status and response to medical care
and treatments.
 DO write legibly. DO use
standard
chart forms.
 DO use only approved
abbreviations.
IV THERAPY DOCUMENTATION
Association of Nursing Services Administration of the Philippines, Inc.
you check the name and
identifying number on the
patient’s chart on each page.
 DON’T chart procedures or
chart in advance.
 DON’T clutter notes with
repetitive or frequently
changing data already charted
on the flow sheet/checklist.
 DON’T make or sign an entry
for someone else DON’T
change an entry because
someone tell you to.
 DON’T abel a patient or show
bias.
 DON’T try to cover up a
mistake or
 accident by inaccuracy or
omission.
 DON’T “white out” or erase an
error.
 DON’T throw away notes with
an
 error on them.
 DON’T squeeze in a missed
entry or
 “leave space” for someone
else who
 forgot to chart. DON’T write
in the
 margin.
 DON’T use meaningless words
and
 phrases, such as “good day”
or “no
 complaints”
 DON’T use notebook, paper or
pencil.

History of IV Therapy in the Philippines

 1991 – RA 7164 (The Philippine Act of 1991) Sec. 27 (a) Art. V states that IV
injection is within the scope of nursing practice.
 1993 – Nursing Standards on Intravenous Practice was established.
  October 1993 – Training for Trainers for ANSAP Board Members and Advisers at
the Philippine Heart Center.
 February 4, 1994 – PRC-BON Resolution No. 08 states that a RN is pohibited
from administering intravenous injections unless he has undergone a special
training.
 1994 - PRC-BON Resolution No. 08 also states that any RN without such training
who administered injections to patient shall be held liable either criminally,
administratively, or both.
 June 9-11, 1994 – Training for Trainers at Cagayan de Oro City.
 May 17, 1995 – Protocol Governing Special Training on the Administration of IV
Injections for RNs adopted ANSAP's IV Nursing Standards of Practice.
 June 13, 1995 – Department Circular No. 100.S.1995 was disseminated by DOH.
 2002 – Special Committee by ANSAP in collaboration with PRC-BON was
founded.
 2002 – RA 9173 (Philippine Nursing Law of 2002) again states that the
administration of parenteral injection is within the scope of nursing practice.
 August 25, 2006 – Nursing Standards on Intravenous Practice 7th ed was released
by Association of Nursing Service Administrators of the Philippines (ANSAP).

The Committee on Nursing Standards on Intravenous Therapy

Ma. Linda G. Buhat, RN, Ed.D.

Jovita R. Pilar, RN, MBA, DPA

Sr. Estrella L. Crisologo, SSpS

Perla B. Sanchez, RN, Ph.D., FPCHA

Leonila A. Faire, RN, MAN

Philosophy of ANSAP

 Envisions itself to be a cohesive, pro-active, professional Association, committed

to excellence in nursing.
 Believes that safe and quality nursing care to patients is the primary responsibility
of nurses.
 Believes that those who practice IV therapy nursing are only those registered
nurses who are adequately trained and have completed the IV Therapy Training
Program for Nurses as prescribed by ANSAP.

Definition of IV Therapy

Intravenous (IV) Therapy –

insertion of a needle into a vein, based on the physician's written prescription. The
needle is attached to a sterile tubing and a fluid container to provide medication and
fluids.

STATUS OF IV THERAPY IN THE PHILIPPINES

Scope of Practice

ROLE DEFINITION
The IV nurses are registered nurses committed to ensure the safety of all patients
receiving IV Therapy.

Definition of Practice

ETHICO-LEGAL IMPLICATIONS:

ANSAP, Inc. upholds quality nursing practice

and is going to continue with the IV Therapy
 Training for the following reasons:

a. Nursing curriculum does not provide in-depth training in parenteral IV drug

administration.
a.1. An in-depth IV Training maybe included in the BSN curriculum but without actual
IV insertion to patients.
a.2. ANSAP believes that
parenteral IV drug administration
is an invasive procedure.
b. The Nurse Administrator has the
command responsibility for the
whole nursing practice in the
Health Care Facility.
c. Globally, the IV Therapy
certification is a mandatory
requirement for the nurse
practitioner
d. IV Therapy Training is voluntary; only those nurses who are adequately trained and
have completed the training requirements in the IV Therapy Program for Nurses as
prescribed by ANSAP will be issued an IV Certificate of Training and the IV Therapy
card of ANSAP
Trends in IV Therapy

 81% - 85% patients in the hospital receive some form of IV therapy

 More nursing time is spent to IV therapy
 Multi-disciplinary health care setting

Why do we need to be updated regarding IV therapy?

 More medications are being administered intravenously now than before.

 Nurses are assuming greater responsibilities related to IV medication
administration.
 Many technical improvements have been made in equipment, and innovative and
time-saving measures have been developed to increase the efficacy of the therapy.

Content of Documentation

 As a general approach nurses are advised to include:

 Details of the assessment and care planned and provided for each episode
of care.
 Relevant information about the condition of the patient at any given time
and intervention taken to response to the patient’s/client’s needs.
 Evidence that all reasonable steps to care for the patient have been taken,
and any action or omissions in providing care have not compromised the
patient’s safety.
 A record of arrangement made for the continuity of care for the
patient/client.

Responsibilities of a Nurse:

 Doing the right thing the first time and all the time.
 Chart and document the important parts of the nursing process.

Areas of Nurse Liability

• Failure to do the following:
• Monitor a patient
• Take proper action when a problem is evident
• Report a problem to the attending physician
• Failure to chart

GENERAL PRINCIPLES OF DOCUMENTATION

1. Accuracy
 Documented observations should give an appropriate picture of the client’s
situation.
 Correct spelling is essential.
2. Complete
 Document ALL pertinent data without omissions of information on client’s
condition.
 Document assessment, problems identified, interventions and evaluation of the
care rendered.
3. Factual
 Must be based on facts of what actually observed, done and evaluated.
4. Clear
 Words used in documentations should be understandable and comprehensible.
5. Appropriate
 Information should be proper and suitable to what actually observed, diagnosed,
done and evaluated.
6. Concise
 Brief and direct to the point.
 Record only what is important.
 Avoid using a long word when a short word will do.
7. Current
 Document the recent and existing condition of the client.
8. Technically correct
 The following should be observed:
 Headings should be completely and properly accomplished.
 Hand writing must be legible.
 All entries must be in a black point pen.
 Each entry must be date and time bounded.
 End entry with a legibly written full name followed by a signature.
 Chart only the observed assessment, problems identified, actions rendered
and evaluation.
 There should be no blank lines or spaces.
 Do not erase nor tamper the erroneous entry, it should be maintained
readable.
 Cross out the erroneous entry making use of a straight line then enclosed
with a parenthesis and write “ERROR” after the entry followed by the
signature of the nurse.
 Entries must be in chronological order.

Do’s in Documentations

 Review notations before signing them. This helps minimize the need for
subsequent corrections or addenda.
 Make all entries at the time of treatment, examination or procedure or as soon
after as possible.
 Draw a line through any empty space at the end of an entry or at the bottom of the
page.
 Complete all boxes or blanks if forms are used. If no information is available or
an item on the form is not applicable, indicate this in the box or blank so that it is
clear that you didn’t disregard the item.
 Make sure the record acknowledges patients complaints and concerns and
indicates that they are taken seriously.
 Include clinically relevant information about a complication, error, misadventure,
etc. How the situation was handled administratively does not belong in the
medical record.
 Stick to the facts and choose your words carefully if a mishap occurs. Do not
argue your case in the medical record. Defensive entries can damage the
credibility of the entire record.
 Use only hospital-approved abbreviations and symbols.
OBSOLETE TERM REASON SUGGESTED PHRASE
conscious & coherent > only for patient's whose > patient oriented to date,
neuro-logical status is time and place

vital signs taken
afebrile
OBSOLETE TERM
due medication given/due
meds given
seen at intervals
needs attended/ kept
comfortable/
kept undisturbed/ kept safe
OBSOLETE TERM
slept fairly/ sleep
well/asleep the whole shift
MGH
on DFA diet/ with fair
appetite/ with good appetite
OBSOLETE TERM
no complaints made/ for
further management
no pain
affected and disoriented
> vital signs are already
written on the monitoring
sheet
> temperature is included in
the monitoring sheet, status
can be deducted here
REASON
> recording of medications
given is in the medication
sheet
> it is expected that we visit
the patient at intervals
> it is expected that we
make the patient
comfortable during their
stay in the hospital
REASON
> only noted if the patient is
having difficulty in sleeping
> not an accepted
abbreviation
> DFA is not an accepted
abbreviation
> include a recording of the
food intake if the appetite
was affected by the illness
REASON
> why document something
th at never happened
> be more specific
> document if you were not
able to take VS and why
> if the patient is febrile,
support it with subjective
and objective cues.
> evaluate effectiveness of
nursing intervention for
fever, include the element of
time
SUGGESTED PHRASE
> document medicines that
were not given and it's
reason
> document stat medicines
given, it's indication and
evaluate the effectiveness
> visit patient frequently
and assess for any
complications
> enumerate measures done
to make the patient
comfortable
> verbalized needs must
also be documented and
referred to the doctors as
necessary
SUGGESTED PHRASE
> if the patient has difficulty
in sleeping; document the
subjective cues,
interventions done and
evaluation.
* Slept for approximately 5
hours as verbalized by
patient”
> "patient seen by Dr.
Gueco, with discharge order
given"
> " patient was able to eat
half of the food served for
lunch“
> include the instruction
given regarding prescribed
diet and the patient's
compliance
* Encourage to eat the
prescribe diet and the
importance. Verbalized
understanding
SUGGESTED PHRASE
> note pain level and
characteristics (PQRST)

S.O. > these are not accepted
abbreviations
Do Not Use Potential Problem
μg (microgram) Mistaken for mg
(milligrams) resulting in
one thousand-fold overdose
cc (cubic centimeters) Mistaken for U (units) when
porly written
AD, AS, AU (right ear, left Mistaken as OD, OS, OU
ear, each ear) (right eye, left eye, each
eye)
OD, OS, OU (right eye, left Mistaken as AD, AS, AU
eye, each eye) (right ear, left ear, each ear)
D/C (discharge or Premature discontinuation
discontinue) of medications if D/C
(intended to mean
“discharge”) has been
misinterpreted as
“discontinued” when
followed by a list of
discharge meds
Forbidden Abbreviations
Do Not Use Potential Problem
U (unit) Mistaken for “0” (zero), the
number “4” (four) or “cc”
IU (International Unit) Mistaken for IV
(intravenous) or the number
10 (ten)
Q.D., QD, q.d., qd Mistaken for each other
(daily) Q.O.D., QOD, Period after the Q mistaken
q.o.d., qod, EOD (every for “I” and the “O”
other day) mistaken for “I”
MS Can mean morphine sulfate
MSO4 and MgSO4 or magnesium sulfate
Confused for one another
> (greater than) Misinterpreted as the
< (less than) number “7” (seven) or the
letter “L”
HS (half-strength) Mistaken as bedtime
hs (At bedtime, hours of Mistaken as half-strength
sleep)
SC, SO, sub q SC mistaken as SL
(subcutaneous) (sublingual); SQ mistaken
as “every,”; the “q” in “sub
q” has been mistaken as
“every”
Abbreviations for drug Misinterpreted due to
names similar abbreviations for
> evaluate patient's response
to interventions done
*Denies any pain at this
time.
> if abbreviations are used
they should be standardize
throughout the agency.
> abbreviations must be
consistent so that they mean
the same thing to all persons
reading the record.
Use Instead
Write “mcg” or
“micrograms”
Write “ml” or “milliliters”
Use “right ear,” “left ear,”
“each ear”
Use “right eye,” “left eye,”
“each eye”
Use “discharge” or
“discontinue”
Use Instead
Write “unit”
Write “International Unit”
Write “daily”
Write “every other day”
Write “morphine sulfate”
Write “magnesium sulfate”
Write “greater than”
Write “less than”
Use “half-strength” or
“bedtime”
Use “subcut” or
“subcutaneously”
Write drug names in full
 multiple drugs
Trailing zero (X.0 mg) * Decimal point is missed Write X mg
Lack of leading zero (.X Write 0.X mg
mg)* • Examples of correct
and incorrect use of
decimal points and
zeros:
Correct Incorrect
2. or 2 2.0
0.2 .2

Don’ts in Documentations
 Use ditto marks or unapproved abbreviations or initials.
 Skip lines or leave blank spaces.
 Try to squeeze in extra words at the end of the line.
 Use terms with more than one meaning.
 Use vague term such as “fair” or “apparently” or “better”.
 Record permanent conclusions.
 Criticize physician’s judgments or recommendations.
 Make defensive notations.
 Erase or obscure anything.

FORMS USED IN IV THERAPY

 Patient and family education form

 Infusion sheet
 Medication sheet
 Multi-disciplinary plan of care
 Multi-disciplinary progress notes
 Hand-over checklist
 Blood transfusion monitoring sheet
CHARTING SYSTEM FORMATS

 Traditional narrative charting

 Problem-oriented medical record system
 Problem-intervention-evaluation system
 Focus charting
 Charting-by-exception system
 FACT system
 Core system

TRADITIONAL NARRATIVE CHARTING

 Advantages:
 Most flexible of all documentation systems.
 Training time needed for new staff members is brief.
 Other health care team members can review the patient’s progress on a
day-to-day basis.
 Can easily present information collected over an extended period.
 Helps to decrease charting time when combined with other documentation
devices.
 Disadvantages:
 You must read the entire record to arrive at the outcome.
 Tracking problems and identifying trends in patient’s progress can also be
difficult and time consuming.
 Tendency to document everything.
 Difficult to retrieve specific information.
 Some may be documented briefly, others at length for no clear reason.

PROBLEM-ORIENTED MEDICAL RECORD SYSTEM (SOAP, SOAPIE,

SOAPIER)

 Advantages:
 Organizes information about each problem into specific categories.
 Illustrates continuity of care, unifying the care plan and progress notes into
a full record.
 Promotes documentation of the nursing process.
 Eliminates documentation of non-essential data.
 Most effective in acute care or long-term care settings.
 Disadvantages:
 Emphasis on the chronology of problems rather than their priority.
 Repetitious charting of assessment findings.
 Resulting overlap makes it time-consuming to perform and read.
 Routine care may be undocumented unless flow sheets are used.
 Difficulties may arise if team members fail to update the problem list
regularly.
 The considerable time and cost of training new personnel to use the
method may also be an disadvantage.
 Isn’t well suited for settings with rapid patient turnover.

PROBLEM-INTERVENTION-EVALUATION SYSTEM

 Advantages:
 Ensures that your documentation includes nursing diagnosis, related
interventions, and evaluations.
 Encourages to meet JCAHO requirements.
 Provides organizing framework for your thoughts and writing.
 Simplifies documentation.
 Promotes continuity of care.
 Improves the quality of progress notes.
 Disadvantages:
 May require in-depth training for staff members.
  Re-evaluation of each problem during each shift is time-consuming and
leads to repetitive entries.
 Omits documentation of the planning step in the nursing process.
 Doesn’t incorporate multidisciplinary charting.

NURSING PROCESS

Progress Notes: Focus charting W/ DAR Format

GATHER DATA

 Assessment checklist
• Physical
• Psycho-social
• Mental-Spiritual
• Environmental
• Diagnostic Results
• Vital signs, initial

ANALYZE DATA
 Maslow’s Hierarcy
 A.B.C.D.
PLAN
 Kardex
IMPLEMENT
 Implementation
• Medication sheet
• Vital signs sheet
• I.V. fluids sheet
• I & O sheet
• Other special forms

Four Elements of Focus Charting

 Focus
 Data
 Action
 Response

FOCUS CHARTING
 Advantages:
 Flexible and can be adapted to fit any clinical setting.
 Centers on the nursing process.
 The format provides cue that direct documentation in a process-oriented
way.
 Easy to find information on a particular problem.
 Encourages regular documentation of patient responses to medical and
nursing therapy.
 Ensures adherence to JCAHO requirements.
 Can be used to document many topics without being confined to those on
the problem list.
 Helps to organize your thoughts and document succinctly and precisely.

 Disadvantages:
 May require in-depth training, especially for staff familiar with other
systems.
 Requires you to use many flow sheets and checklists.
 Can be a narrative note if you neglect to include patient’s response to
interventions.
CHARTING-BY-EXCEPTION SYSTEM

 Advantages:
 Decreases the time needed to document normal and abnormal findings.
 Promotes uniform nursing practice.
 Flow sheets lets you easily track trends.
 Abnormal findings are highlighted.
 Documentation of routine care is eliminated.
 Information that has been recorded isn’t repeated.
 Disadvantages:
 Major time commitment needed to develop clear guidelines and standards
of care.
 Doesn’t accommodate integrated or multidisciplinary charting.
 May be questioned in court until the system becomes more widely known.

FACT SYSTEM
 Advantages:
 Eliminated repetition.
 Encourages consistent language and structure.
 Outcome oriented.
 Communicates patient progress to all health care team members.
 Permits immediate recording of current data.
 Eliminates the need for many different forms.
 Reduces the time spent writing narrative notes.
 Disadvantages:
 Requires major time commitment to develop standards and implement the
system.
 Narrative notes may be too brief.
 Nurse’s perspective may be overlooked.
The nursing process framework may be difficult to identify.

CORE SYSTEM
 Advantages:
 Incorporates the entire nursing process into one system.
 Groups nursing diagnosis and functional assessment together, allowing
various solutions.
 Promotes concise documentation.
 Encourages the daily recording of psychosocial information.
 Useful in acute care and long-term care facilities.
 Disadvantages:
 May require in-depth training for staff members who are familiar with
other systems.
 Developing forms may be costly and time-consuming.
 Doesn’t always present information chronologically.
 Progress notes may not always relate to the care plan.
