2.5 Documentation
Open Resources for Nursing (Open RN)
Using Technology to Access Information
Most client information in acute care, long-term care, and other clinical settings is now electronic and uses intranet technology for secure access by providers, nurses, and other health care team members to maintain client confidentiality. Intranet refers to a private computer network within an institution. An electronic health record (EHR) is a real-time, client-centered record that makes information available instantly and securely to authorized users.[1] Computers used to access an EHR can be found in client rooms, on wheeled carts, in workstations, or even on handheld devices. See Figure 2.11[2] for an image of a nurse documenting in an EHR.
The EHR for each client contains a great deal of information. The most frequent pieces of information that nurses access include the following:
- History and Physical (H&P): A history and physical (H&P) is a specific type of documentation created by the health care provider when the client is admitted to the facility. An H&P includes important information about the client’s current status, medical history, and the treatment plan in a concise format that is helpful for the nurse to review. Information typically includes the reason for admission, health history, surgical history, allergies, current medications, physical examination findings, medical diagnoses, and the treatment plan.
- Provider orders: This section includes the prescriptions, or medical orders, that the nurse must legally implement or appropriately communicate according to agency policy if not implemented.
- Medication Administration Records (MARs): Medications are charted through electronic medication administration records (MARs). These records interface the medication orders from providers with pharmacists and are also the location where nurses document medications administered.
- Treatment Administration Records (TARs): In many facilities, treatments such as wound care are documented on a treatment administration record.
- Laboratory results: This section includes results from blood work and other tests performed in the lab.
- Diagnostic test results: This section includes results from diagnostic tests ordered by the provider such as X-rays, ultrasounds, etc.
- Progress notes: This section contains notes created by nurses and other health care providers regarding clientcare. It is helpful for the nurse to review daily progress notes by all team members to ensure continuity of care.
View a video of how to read a client’s chart.[3]
Legal Documentation
Nurses and health care team members are legally required to document care provided to clients. Any type of documentation in the EHR is considered a legal document. In a court of law, it is generally viewed that, “If it wasn’t documented, it wasn’t done.” Other documentation guidelines include the following:
- Documentation should be objective, factual, and professional. Only document what you perso