NCM 104/107 - DOCUMENTATION
āIF YOU DIDNāT DOCUMENT IT, YOU
DIDNāT DO ITā
NURSING DOCUMENTATION
ļ·Refers to the record of nursing care
that is planned and delivered to
individual clients by qualified nurses or
other caregivers under the direction of
a qualified nurse.
ļ·It contains information in accordance
with the steps of the nursing process.
PURPOSES OF DOCUMENTATION
ļ·Provides a written record of the
history, treatment, care, and response
of the patient while under the care of a
care provider.
ļ·Guide for reimbursement of costs of
care.
ļ·May serve as evidence of care in a
court of law.
ļ·Shows the use if the nursing process.
ļ·Provides data for quality assurance
study.
PURPOSES OF DOCUMENTATION IN
LEGAL PROCEEDINGS:
ļ·To prove or disprove evidence of
breach.
ļ·To draw conclusions or make
inferences.
ļ·To prepare a statement claim and
counterclaim.
ļ·To use as evidence at trial.
ļ·To provide to the experts for review
and analysis.
TYPES OF DOCUMENTATION
ļ·SOURCE ORIENTED CHARTING
(NARRATIVE CHARTING)
ļ·POMR (PROBLEM MEDICAL
RECORD ORIENTED)
ļ·PIE (PROBLEMS, INTERVENTIONS,
AND EVALUATION)
ļ·FOCUS CHARTING (FOCUS, DATA,
ACTION, AND RESPONSE)
ļ·CPE (CHARTING BY EXCEPTION)
ļ·COMPUTERIZED DOCUMENTATION
(ELECTRONIC HEALTH RECORDS)
ļ·CASE MANAGEMENT
SOURCE ORIENTED CHARTING
(NARRATIVE CHARTING)
ļ·The ātraditionalā client record.ī
ļ·A source-oriented medical record
(SOMR) is a conventional method of
preserving patient data in which
observations, actions, and results are
recorded by departments or
healthcare providers in specific
parts of the patientās file.
POMR (PROBLEM ORIENTED MEDICAL
RECC
ļ·The Problem-Oriented Medical Record
(POMR), established by Dr. Lawrence
Weed in the 1960s, represents a
significant shift in medical
documentation by organizing patient
data around specific problems rather
than by the source of the information.
This method is structured to enhance
clarity, continuity, and
comprehensiveness in patient care.
Basic Components:
ļ·Database
ļ·Problem
ļ·Plan of Care
ļ·Progress Notes
The Four (4) Basic Components
1. Database. A complete history and
physical examination, along with initial
lab results and diagnostic tests,
provide a baseline of patient
information.
2. Problem List. Derived from the
database. Usually kept at the front of
the chart & serves as an index to the
numbered entries in the progress
notes. Problems are listed in the order
in which they are identified & the list is
continually updated as new problems
are identified & others resolved.
3. Plan of Care. For each identified
problem, initial plans are developed
and documented. These plans are
divided into three categories:
diagnostic (further tests needed),
therapeutic (treatment plans), and
