Nursing Foundations · Documentation & Reporting

Documentation & Reporting

Documentationdefinition

A written record of patient care that promotes continuity of care by communicating among healthcare professionals.

in simple words: The chart is the central information hub that coordinates doctors, nurses and therapists and prevents fragmented care.

e.g. Recording assessments, medications, education and vital signs.

Purposes of Documentation

Primary – Continuity of care – communication among healthcare professionals.
Secondary – Research use, hospital reimbursement, legal protection, audit of care quality.
Supports – Indexing and retrieval, standardised formats, billing.
Not a purpose – Delay in decision-making; inventory re-order statements.

Principles of Good Documentation – Accuracy, Conciseness, Thoroughness, Legibility, Permanence, Timeliness, Objectivity

Accuracy – factual and objective; no opinions.
Conciseness – brief and relevant only.
Thoroughness – all assessment, intervention and response details.
Legibility – clear and easy to read; illegible orders must be clarified, never guessed.
Permanence – durable and non-erasable; permanent ink.
Timeliness – record each encounter immediately after it occurs.
Objectivity – avoid subjective interpretations.

Documentation & Reporting · Nursing Foundations

Methods of Recording

Problem-Oriented Medical Record (POMR)definition

Organises patient data around a list of identified problems and uses the SOAP format for progress notes.

in simple words: SOAP = Subjective, Objective, Assessment, Plan.

e.g. Subjective: patient reports pain; Objective: vital signs; Assessment: nursing judgment; Plan: interventions.

Documentation Formats

Format	Key feature
SOAP	Subjective, Objective, Assessment, Plan
SOAPIE	Adds Intervention, Evaluation
SOAPIER	Adds Revision to SOAPIE
DAR (Focus charting)	Data, Action, Response
Source-oriented	Separate sections per discipline
Charting by exception	Only significant findings/deviations

Other Systems

Case management – Manages care to achieve outcomes within a timeframe using critical pathways.
Charting by protocol – Documents care delivered according to pre-established institutional protocols.
Kardex – Concise summary of diagnoses, medications, treatments and nursing orders for quick reference.

Documentation & Reporting · Nursing Foundations

SOAP & DAR

SOAPdefinition

A problem-oriented format: Subjective, Objective, Assessment, Plan.

in simple words: S = what patient says; O = measurable data; A = professional judgment; P = intended action.

e.g. S: 'I feel dizzy'; O: BP 90/60; A: risk for falls; P: assist with ambulation.

DAR (Focus Charting)definition

A patient-centred system using Data, Action, Response.

in simple words: Focus may be a problem, strength, concern or significant event.

e.g. Data: pain 8/10; Action: analgesia given; Response: pain reduced to 3/10.

SOAPIEdefinition

Extends SOAP with Intervention and Evaluation.

in simple words: I = specific nursing actions; E = patient outcome.

e.g. Intervention: repositioned; Evaluation: pressure area intact.

Documentation & Reporting · Nursing Foundations

Guidelines & Legal

Medication Documentation

Timing – Document immediately after giving the medicine (name, dose, route, time).
Delay – Even one hour delay is unsafe – risks double-dosing.
Vomiting – Assess vomit for pill, inform doctor, document event and orders.
Discrepancy – Report immediately to supervisor.
Alteration – Erasing or altering is illegal – falsification.

Correcting a Paper Error

Draw single linethrough the error
Write 'error' or 'mistaken entry'
Add initials, date, time

Documentation & Reporting · Nursing Foundations

Confidentiality

Confidentialitydefinition

The ethical and legal obligation to protect a patient's private information from unauthorized disclosure.

in simple words: Share only with those directly involved in care, with consent, or when required by law.

e.g. Breach can lead to lawsuits, fines, job loss and loss of licence.

Informed Consentdefinition

Disclosure of information to the patient so they can make a knowledgeable, voluntary decision.

in simple words: Covers diagnosis, nature, purpose, risks, benefits, alternatives, consequences of no treatment.

e.g. Doctor obtains consent; nurse verifies understanding and documents it.

Implied Consentdefinition

Applies in an emergency when an unconscious patient needs immediate life-saving treatment.

in simple words: Law presumes a reasonable person would consent to life-saving treatment.

Documentation & Reporting · Nursing Foundations

Reporting & Records

Types of Reports

Report	Purpose
Shift report	Primary communication tool for continuity between shifts
Hand-off report	Transfers patient information and responsibility at shift change
Incident report	Documents adverse events/near misses; not part of medical record
Assignment record	Administrative delegation of patient care responsibilities

Types of Client Records

Anecdotal record – Brief, objective description of a single observed behavior or incident; documents all significant incidents, positive and negative.
Clinical record – Comprehensive medical file containing entire health history, diagnoses, treatments.
Cumulative record – Long-term collection of data over many years.
Incident/variance report – Specific tool for documenting adverse events; confidential, for risk management.