Documentation Principles in Health Care

Record keeping and documentation practices should be followed to ensure the patient
unit health records (UHR) is up to date and maintained according to laws and acceptable
professional practices and principles. Health records should be complete, timely and concise.
The entries should address documentation requirements and be specific, timely, accurate,
concise clear and legible. All inpatient documents should be completed within fourteen days
after discharge of a patient. The entries should be recorded in a chronological sequence as
every activity is done (Ohlen, Forsberg and Broberger).
Record entries should be permanently recorded, either typed or with permanent ink
that cannot be erased or fade. Authentication of every document entry; time, date and sign of
all entries, professional designation should be showed and no one should sign for another
individual. The entries should be consecutively filled with no skipping of lines and leaving of
unfilled spaces. Patient records are confidential and nothing should be discussed about the
patient to others without their permission. Accuracy should be considered in each entry where

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exact figures are entered and entries done correctly and professionally (Fairchild and
Pierson).

Purpose of Health Records

Health records may be in electronic form, paper form or both, they provide vital
information, diagnoses, history of examination and treatment. Health records are a means of
communication in facilitating safe treatment and care of a patient. It is the primary source of
information including therapeutically and medical interventions and treatment for the
wellbeing of a patient during a care episode and informs on future episodes (Menachemi and
Singh). The records may be used for communication with external statutory bodies,
regulatory bodies and health care providers; in additional to providing patient safety
improvements, planning, audit activities, investigating complaints, financial reimbursement,
education and public health. Records are an important piece of evidence which protects the
legal rights of health care personnel, patient and PHO or other personnel.
Documentation Written by an Activity Professional

Recording and reporting systems pertaining to clients have evolved. Narrative
charting is one of traditional nursing document written chronologically in graphs that
describe patient status, interventions and treatments. It is usable in all clinical setting as it is
the most flexible of all system and illustrates the relationship between patient’s response and
nursing interventions. Problem Oriented Medical Record (POMR) employs logical structured
format and focus on the patient’s problem. The charting is based on SOAP, SOAPIE and
SOAPIER; S-subjective data, O-objective data, A-assessment, P-plan, I- implementation, E-
evaluation and R- revision (Carpenito).

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Pie charting is a system developed in streamlining documentation with its main parts
is integrated assessment flow sheets, plan of care and nurse’s progress notes. A source
oriented charting is a narrative recorded by each health care member on separate document
and it is time consuming. Charting by exception (CBE) is a standard protocol that states the
expected illness cause and significant findings are documented in narrative form. Its
assumption is, patient’s care needs are routine and predictable and that the patient’s response
and outcome is routine and predictable (Carpenito).
Focus charting is a system using column format to chart Data, Action and Response
(DAR). It is a nursing diagnosis and acts as sign or symptom, patient behaviour, special need,
treatment procedure and acute change in client need. The column format of the system is used
in progressive notes but it is distinguishable from other entries. Computerized documentation
is used in every health facility in ordering medication and diagnostic test and receiving the
same. It increases accuracy, reduces documentation time and stores and retrieves information
quickly (Cohen).

RAI Completion

RAIs should be the foundational tool in facilities rather than a supplement with MDS
and RAPS acting like the main assessment tools, other assessments collect information that
supplement comprehensive assessment. It assesses the newly admitted clients within 14days,
it conducts annual reassessment. No less than 92days (every quarter), facilities review
comprehensive assessment that assure resident assessment is accurate and reflect current
status of the resident. Comprehensive assessment is completed within 14days when the
facility determines physical significant change of the resident (f274). The facility addresses
all residents’ needs and strengths regardless of their inclusion in RAPS and MDS (Ohlen,
Forsberg and Broberger).

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Goal of Initial Assessment in Nursing

Patient assessment is focused on the patient governed by notion of an individual’s potential,
perceived and actual needs. It provides the baseline information of planning the outcome and
care interventions to be achieved (Carlisle). It is vital to structure patient assessment in
detecting emergency of new problems and monitoring the success of care. A good rapport is
required in the start of interview and confidentiality should be emphasized for exact
information to be derived.

Works Cited

Carlisle, Susan. “The Royal Marsden Hospital Manual Of Clinical Nursing Procedures –
Eighth Editionthe Royal Marsden Hospital Manual Of Clinical Nursing Procedures – Eighth
Edition”. Nursing Standard 26.9 (2011): 30-30. Web.
Carpenito, Lynda Juall. Nursing Care Plans & Documentation. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins, 2009. Print.
Cohen, Michael R. “Patient Documentation”. Nursing 37.7 (2007): 12. Web.
Fairchild, Sheryl L, and Frank M Pierson. Pierson And Fairchild’s Principles & Techniques
Of Patient Care. St. Louis, Mo.: Elsevier, 2013. Print.
Menachemi, Nir, and Sanjay Kumar Singh. Health Information Technology In The
International Context. Bingley, U.K.: Emerald, 2012. Print.

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Ohlen, A., C. Forsberg, and E. Broberger. “Documentation Of Nursing Care In Advanced
Home Care”. Home Health Care Management & Practice (2013): n. pag. Web.