By :

Wilhelmina G. Bernardo, RN, RM, MAN

 The quality of records maintained
by nurses is a reflection of the
quality of the care provided by them to
patients / clients
Nurses are professionally and legally
accountable for the standard of
practice which they deliver and to
which they contribute. Good practice
in record management is an integral
part of quality nursing practice.
 Since the time of Florence Nightingale,
nurses have viewed documentation as a very
important aspect of their professional
practice. Nightingale described the need to
document proper use of air, light, warmth,
cleanliness and proper selection of diet with
an aim of collecting and retrieving data to aid
in proper patient management.
 Iyer, Levin & Shea, (2006) confirmed that
whereas the aim of documentation in
Nightingale’s time was mainly to communicate
implementation of Doctors orders, today’s
nursing documentation is applied in all the
steps of the Nursing process from assessment
to evaluation.
  Virginia Henderson, a Nurse theorist,
promoted the use of documentation when she
introduced the idea of using the nursing care
plans to communicate nursing care during
the 1930’s. However, the nursing
documentation was discarded after the
patient had been discharged. Since 1970’s,
nursing documentation has become more
important reflecting the changes in nursing
practice, regulatory agency requirements and
legal guidelines
 Nursing documentation
has also evolved as an important mechanism
in determining monetary reimbursement
of the care provided to clients/patients
(Iyer et al., 2006).
 Effective communication among health
professionals is vital to the quality of client
care
 Generally, health personnel communicate
through discussion, reports and records.
 A discussion is an informal total
consideration of a subject by two or more
health care pesonnel to identify a problem or
to develop strategies to solve a problem.
 A report is oral, written or computer-based
communication intended to convey
information to others.
 A record is written or computer-based.
 The process of making an entry on a client
record is called recording, charting, or
documenting.
 a client record, also called chart or client
record is a formal, legal document that
provides evidences of a client’s care.
Written evidence of pt. in the administration
of test, procedures, treatment and
client education.

The results of clients response

to diagnostic test and
interventions

Written evidence of the interactions

between and among health professionals,
clients, their families and
health care organizations.
Accountability Communication

Professional Education
responsibility

Research

Meeting legal and Reimbursement

practical standards

Statistics
 Recording is a method of
communication that validates
the care provided to the client.
It should clearly communicate
all important information
regarding the client.
It provides efficient and effective
methods of sharing information
 Health care students use
the medical record as a tool to
learn about the disease process,
complications, medical surgical diagnosis
and interventions.
Rely on clients medical records as
a clinical data source to
determine if clients meet
the research criteria for study.
 Failure to document is a
key factor because medical record
is a legal document and
in case of lawsuit the records
serve as a
description of exactly
what happened to the client.
 Provides statistical information
can be utilized for planning people’s future
needs.
 Provides the basis for decisions
regarding care to be provided
and subsequent reimbursement to
the agency,
to cover health-related expenses
 When nurses undertake to practice
their profession they are held responsible
and accountable for the quality of
performance of their duties.
The standard is a clearly defined legal
expectation to which nurses are held
accountable.
Review of records can be done to check
if standards are being followed.
Monitors the quality of care
received by the client
and the competence of
health-care givers
 Environmental Factors (safety, equipment), self care,
client education
 Clients outcomes, clients response to treatments, or
preventive care
 Discharge assessment data
 More comprehensive notations to clients who are
seriously ill
 All relevant assessment data, including monitoring strips
 Information related to any client transports
➢ Collaboration / communication
with other health care providers
➢ Medication administration
➢ Verbal orders
➢ Telephone orders
➢ Giving and receiving verbal orders is considered a high
risk activity .

➢ Miscommunication or lack of communication could

lead to negative implications for the client.

➢ nurses & physicians have shared the responsibilty

CLEARLY,

COMPREHENSIVELY,

COMPLETELY,

ACCURATELY ,

HONESTLY
 Legibility and spelling

Forms, flow sheets,

Checklists and progress notes

Blank space

Changes or additions

Abbreviations
TIMELY

FREQUENTLY

CHRONOLOGICALLY
 Documentation should be done as soon as possible after
an event has occured.

Ex.
• Care provided,
• medication administered,
• client fall.
 FREQUENCY OF DOCUMENTATION
SUPPORTS ACCURACY
particularly when
precise assessment is required as
a result of client conditions ex.
Intensive care, fluctuating health status
• Late entries should be made according to
agency policy.

• Late entries must be clearly identified

(addendum to care) and should be
individually dated, time and must be signed
by the nurse involved
 Nurses need to refer to agency policy
and may reconstruct the entry by clearly
indicating the care/event as a
replacement for
a lost entry
 DOCUMENTING EVENTS IN THE
CHRONOLOGICAL ORDER IN WHICH THEY
TOOK PLACE IS IMPORTANT , PARTICULARLY IN
TERMS OF REVEALING CHANGING PATERNS IN A
CLIENTS HEALTH STATUS.
Also enhances the clarity of communications,
enabling health care providers to understand
what care was provided.
:
➢COST HOSPITALS REIMBURSEMENT PESOS WHEN THERE IS
NO DOCUMENTATION OF THE SERVICES THAT WERE GIVEN

 HAMPER QUALITY ASSURANCE AND RISK MANAGEMENT

EFFORTS.

 FORCE HOSPITALS TO SETTLE SUITS OUT OF COURT TO

LOSE CASES BECAUSE LAWYERS CANNOT PREPARE A SOLID
DEFENSE

NOTE: 85% OF MALPRACTICE CASES THAT COULD BE

•
DISMISSED FOR LACK OF EVIDENCE END UP IN COURT
BECAUSE THE PATIENT RECORD IS TOO POOR TO DEFEND
THE HOSPITAL.
REQUIRES:
❖ Proper use of spelling and grammar
❖ Use of authorized abbreviation
❖ Legible and neat writing
❖ Factual and time sequenced descriptive notation
 Ensure that you have the correct client record
 Document as soon as possible to ensure
accurate recall of data
 Date and time each entry
 Sign each entry with your full legal name
and with your signature
 Do not leave space between entries
 Use quotation marks to indicate direct client responses
 Document in a chronological order if not state why
 Write legibly
 Use of permanent ink
 Document in a complete and but concise manner
Check that you have the:
▪ Correct chart
▪ Reflects nursing process
▪ Write legibly
▪ Chart the time you gave medication, the
administration route, and patient’s
response
▪ Chart precautions or preventive measures
used
▪ Record each phone call to a physician
▪ Chart patients care at the time you provide it
▪ If you remember an important point after
you’ve completed your documentation,
▪ Chart the information with a notation
• Document often enough to tell the whole story
• Don’t chart a symptom such as c/o pain
• Don’t alter a patients record
• Don’t use short hand or abbreviations that
aren't widely accepted
• Don’t write imprecise descriptions
• Don’t chart what someone else said, heard, felt
or smelled unless information is critical
• Don’t chart ahead of time
1. brevity
• Entries are concise
• Complete sentences are not required
• Start each entry with a capital letter and end the
entry with a period even the entry is a single
word or phrase.
2. Use of Ink or Permanence
• Avoid the felt pen or pencil for permanence of
data, because the client’s chart can be used as
an evidence in a legal court.
3. Accuracy
• Chart objective facts, not your interpretations or
opinions.
• E.g.
➢ Correct – ate 50% of the food served
➢ Incorrect – ate with poor appetite
➢ Correct – seen crying
➢ Incorrect - depressed
• Placed complaint of the client in quotation
marks to indicate that it is statement
➢ E.g. complaint of “chest pain radiating down
the left arm”

• Objective data are also to be charted

➢ E.g. skin cold and clammy. Diaphoretic.
Prefers to sit up. Vital signs taken as follows :
TEMP = 37.6 C, PR= 110/min.,
RR=26/min.,BP=146/90
• Describe behaviors rather than feelings to
allow other health team members to
determine the actual problems of the client.

• Refusal of medications and treatments must

be documented.
4. Appropriateness
• Only information that pertain to the client’s
health problems and care are recorded.

• Any other personal information that is

conveyed to the nurse is inappropriate for the
record.
5. Completeness and
Chronology/Organization/Sequence/Timing

• Notes should appear on each succeeding line.

• Continuous charting is done for each entry

unless a time change occurs. No need for a
new line for each new idea or entry.
• Date is entered on the date column on the
first line of every page of nurse’s notes and
whenever the date changes.

• Time is entered in the time column whenever

a new time entry occurs.

• Avoid time changes in the text of the nurse’s

notes.
• Avoid double chart. If something appears on
a particular sheet, it does not need to appear
on the nurse’s notes, unless there is
alteration from the normal, E.g. Body
temperature, blood pressure.

• Avoid sequencing information into a space

because you forgot to chart it earlier. Add the
information on the first available line. Write
the time the event occurred, not the time you
entered the information.
 The following information should be charted:
- Physician’s visit
- Time the patient leaves and return to the
unit, mode of transportation and
destination
- Medication should be charted
immediately after given
- treatments should be charted
immediately after administered.
6. Use of standards terminology
• Use only those abbreviations and symbols
approved by the institution; spell
correctly; use proper grammar
7. Signed
• Affix signature, place at the end of the
charting, at the right hand margin of the
nurse’s notes.
• Sign each entry with your full name and
status, eg. SN for student nurse, RN for
registered nurse
• Script not printing is used for the signature
8. In Case of Error

• Correct errors by drawing a single

(horizontal) line through the error.

• Write the word error above the line, and then

sign your signature

• No ink eradication, erasures or use of

occlusive materials.
Eg.
Error wgb
Pulse 180beats /min. 108 beats/min.
9. Confidentiality

• Only the health personnel who participate in

care of the client are allowed to read the
chart.
10. Legal Awareness

• Chart only what you personally have done,

observed, heard, smelled or felt

• Do not discard any part of the client record.

11. Legible

• Writing must be clear and easily read by

others.

• If writing is not legible, then print.

12. Do not use the word “patient” or “pt” in
the chart; the chart belongs to the patient.
All information in the chart pertains to the
patient.
13. A horizontal line is drawn to fill up a partial
line. This is to prevent other persons from
adding information in the nurse’s notes.

wgbernardo
Eg. ---------------WilhelminaG.Bernardo,RN
 1. Charting should be consistent with your
employers written policies
 2. If you did it or saw it, you should chart it
 3. If you didn’t chart it, you didn’t do it
 4. Charting should include any interactions
with staff members or doctors, including
failed attempts to reach them,
concerning the care of a patient
 5. Do not erase an error or remove pages,
draw a line thru the error, note, it was an
error and initial it
 6. Records should be clear, legible, accurate
and should use proper terminology
 7. Chart chronologically at the time of
occurrence or as soon as possible
afterward
 8. Charting should be in inked and signed
appropriately
Flow Sheets
 These are often called “graphic records” and
used as a quick way to reflect or show clients
condition.
 They are helpful records in documenting this
such as vital signs, medications, intake and
output, bowel movements, etc. the time
parameters for a flow sheet can range from
minutes to months
 It is essential that health professional caring
for a patient have current information about
the patient’s condition, goals and progress
 Registered nurses are responsible and
accountable for their nursing practice and
conduct and they can be held legally
accountable for those actions.
 Documentations can be used to determine
whether or not the care provided met
required standard.

 Documentation of nursing care includes the

plan of care, client goals, client responses
to care, and the registered nurses clinical
decision making
 Charting
is an integral part of professional patient care
rather than something that “takes away from
patient care.” Adequate
documentation facilities, good
communications can protect both the
patient and the registered nurse
 The patient’s status changes or doesn’t improve
as expected.
 Other members of the health care team have
been notified of a change or lack of
change in a client’s condition
 The patient is being transferred between
units or facilities
 The patient is engaged in risk-taking behavior
 The patient refuses care
 An unanticipated, unexpected or unusual
incident occurs with the patient, staff or
family
 An error/mishap/accident occurs
 Consider the time and financial cost of
inadequate documentation
 Avoid duplication
 Keep charts or flow sheets close to where care
is given
 Review the list of activities you do everyday
that can be done by someone other than a
registered nurse, you can’t delegate
documentation
Provide appropriate space for registered nurses
to think and document.
Advocate for user-friendly charting policies
and systems that
demonstrates nursing
accountability and professional judgment.
 Advocate for point of care charting, such as
flow sheets, medications, administration records, etc.
 Department heads and supervisors to
revise job description so that
documentation responsibilities of all
Professionals are well defined.
 Forms used for documentation if they
facilitate or hinder documentation or
recording, revise, if there is a need,
evaluate
Sanchez stated:
We must always stress the importance of a
complete accurate and up to date
documentation because it does not only project
the image of an efficient conscientious
and reliable staff but more importantly,
it gives the impression to patient that he is being
taken cared of properly
FRIEND

OR

ENEMY
 In a mal practice suit, good documentation in the
medical records can be ones best friend or worst
enemy.
 If a claim is not settled an proceeds to trial, the most
important evidence presented to the COURT is the
medical record.
 The COURT uses the medical record as a legal guide
to assess the health care providers professional
conduct to determine whether they adhered to or
deviated from the standard
 As a preventive liability
tool. If a nurse does not
document the care
provided, treatments may
jeopardize the patient’s safety
 In conclusion, the nurse documentation is a
legal record that provides information about
 the continuity of care from admission to
discharge.
 Careful documentation is one of the best
defenses against liability exposure and
provides a supportive record of medical and
treatment interventions and evidence of
quality of patient care
 It is important to
remember the basics for good documentation to
protect yourself legally and to be able to provide
good care to your patients.
 Remember that what
you write today, can
save you and your
license in the future,
should the record end
up in a court room.
 Keep in mind, whether
your facility uses any
type of documentation
systems, you need to
document your actions
expertly
BY FOLLOWING THESE TIPS
AND GUIDELINES, YOU
WILL BE WELL ON YOUR
WAY TO PROTECTING
YOURSELF LEGALLY AND
PROVIDE THE BEST
POSSIBLE CARE TO YOUR
PATIENTS
 QUALITY DOCUMENTATION &
RECORDING ARE THE
ESSENCE OF A GOOD QUALITY
MEDICAL RECORD HAS
ALWAYS BEEN CONCERN IN
HEALTH CARE …… WHY ?

THE RISK TO HUMAN LIFE

 AND WE WILL SAY IT
ONE MORE TIME….

“IF YOU DIDN`T CHART

IT, IT WASN`T DONE”.
THANK YOU!!!!
References :
1.Villaluna, Zenaida L. ,et. al, Hospital
Nursing Service Manual, DOH
2. Villaluna, Zenaida L., Lecture on
Documentation