5 Documentation of Health Assessment Findings

I.  Overview of Documentation of Assessment Findings

In the article Nursing record systems: effects on nursing practice and healthcare outcomes by Urquhart C, Currell R, Grant MJ, Hardiker NR nurses document to record the care that was planned, any deviations, and the actual care given to each patient by the registered nurse (RN) or any caregivers working with the RN to provide patient care.

The article further states that documentation should demonstrate the legality of the care given and should be professionally completed. Nursing documentation is legal when it includes timely, accurate, and completes notes. Legally only actions or care documented are seen as being completed. This sentiment is reflected by the nurse’s mantra of “If it was not documented, it was not done.” It is important that these rules apply to written documentation in the physical chart and in electronic charting (EHR).

The article further states that documentation should demonstrate the legality of the care given and should be professionally completed.  Legally only actions or care documented are seen as being completed. This sentiment is reflected by the nurse’s mantra of “If it was not documented, it was not done.” It is important that these rules apply to written documentation in the physical chart and electronic health record (EHR).

Documentation in all formats need to be clear, concise, accurate, timely, with minimal use of abbreviation, in the correct chart.

Documentation should contain objective charting that avoids opinions about the patient, family, or other caregivers, and is written in grammar-appropriate standard English. Remember, if the note goes to court it is important that the jury can read it grammatically and legibly.

Nursing documentation is needed for the following reasons:

• Shares the created plan of care for each patient
• Communicates findings: assessment changes, abnormal labs or test results, consultation reports, communication between health care team members.
• Ensures continuity of care across shifts-by sharing the individualize care given to each patient
• Provides proof of patient education given to the patient and/or patient and support system
• Monitors quality assurance-e.g., turning every 2 hours to maintain skin, putting on special socks and room identifiers to identify patient at risk for falls.
• Validates reimbursement by creating a record of payable nursing services for payors, e.g., Insurances, Medicare, and Medicaid.
• Identifies usage of research and research-based interventions
• Records discharge concerns/readiness-homecare needs
• Addresses the legality of care given – “If not documented not done.” Legal documentation is accomplished when all part of the nursing process: the assessments, planning-patient goals, nursing interventions, and the evaluation-responses to treatment are within the note.

According to the “The Uses of Nursing Documentation,” by American Nursing Association (2010) and the Seven criteria for nursing documentation presented in 2010 by Jefferies, Johnson, and Griffiths in the paper: “A meta-study of the essentials of quality nursing documentation.”

More complicate purposes for nursing documentation include:

• Records individualized evidenced based interventions used to apply individualize care
• Reflects the nurse’s clinical judgement behind decisions made while caring for the patient
• Provides proof of nursing’s contributions to patient care outcomes and to the viability and effectiveness of the organizations in which nurses complete patient care.
• Incorporates ethical principles of nursing including integrity, honesty, and accountability when documenting patient care activities especially when informed consent for a procedure of test has been obtained. (hidaje, hidaje H. 2024)
• Demonstrates application of accreditation, credentialing, regulatory and legislative, reimbursement, research, and quality activities standards in patient care provided.
• Indicates the quality nursing practice and patient mortality
• Affects the financial status of the organization, hospital, clinic, or office where care was provided.
  • Missing, incomplete or inaccurate documentation can affect how a patient risk adjustment and patient acuity are assessed and therefore will determine how payer compliance (Megan Chamberlin 2024)

Lastly, In the article “Defensive Documentation: Steps Nurses Can Take to Improve Their Charting and Reduce Their Liability,” by Georgia Reiner presents tips on how to document safely.

Electronic documentation (EMARS)  facilitates an accumulation of data including: lab and test results, delegated task, consultation reports, patient communication to the nurse and other health care team members, patient teaching and patient adherence to plan of care.

• When using electronic documentation the nurse should:
  • Abide by HIPAA.
  • Correcting errors promptly
  • Document who was delegated which task
  • Use only appropriate/approved abbreviations
  • Refrain from copying and pasting in electronic records
  • Document refused medication or treatment-non-adherence by the patient
  • Use this tool to obtain and report lab/ test results and consultation reports quickly

The primary care provider (MD, NP, PA), consulting physicians, social worker, physical therapist, occupational therapist,  nutritionist, and possibly the clinical pharmacist all use the progress note section to document.

Nurses use a specific section in the chart called the “Nurse’s Notes” or document in the progress note section with all other interdisciplinary team members to communicate the patient’s status, deviations from the plan of care, teaching completed, and discharge preparation.  It is important that the nurse read the physical or electronic progress note to obtain information from each of the interdisciplinary team member to determine the patient’s course of care, barriers to wellness, and possible discharge dates.

All types of documentation must have the date, time, and signature of the person documenting.

II. When does the nurse document?

• At admission to a unit or procedure
• When accepting a transfer or sending a transfer to another floor.
• After the head to toe assessment
• After a focused assessment when a change in patient status has been noticed.
• After medication administration, especially after the administration of pain medication.
• After any teaching is given.
• After any wound inspection or wound dressing change.
• Progress notes every two hours, after a change in patient status, after an emergency, or at the end of a shift depending on the hospital policy.
• At the occurrence of significant events.
• As per unit/hospital policy

III. The nurse may use different types of documentation.

The type used is normally mandated by the hospital. Documentation may differ to meet the needs in the critical care areas e.g., the Emergency Department, the Intensive Care Units (ICUs), Hemodialysis and Psychology.

The most commonly used types of documentation are listed here:

• Charting by Exception Noted: Only the abnormal findings on an assessment are recorded and it is also used to document communication with other health care providers.
• Focused DAR Notes which utilizes Charting by Exception:
  • D for Data: All assessment findings plus vital signs. The data section corresponds with the assessment portion of the nursing process.
  • A for Action: All nursing actions and incorporates the planning and implementation stages of the nursing process.
  • R for Response: this section documents the patient’s response to the nurse’s action and evaluates if the nurse’s action (intervention) worked or not. This incorporates the Evaluation phase of the nursing process.

• • View sample charting by exception paper documentation with associated DAR notes for abnormal findings. Please click on the link and open it in a new window to see the example.
  • For more information about writing DAR notes, visit What is F-DAR Charting?

The third type of note is the Narrative note:

• Narrative Notes are a type of progress notes that give a short snapshot of the patient’s status, assessment findings, nursing activities, and care given at certain chronological intervals during the entire shift. Please use this link Guide to Documentation for Nurses to see examples of the Narrative note.

The fourth type of note is the SOAPIE:

• SOAPIE is a mnemonic for a type of progress note that is organized into six categories: Subjective, Objective, Assessment, Plan, Interventions, and Evaluation.
  • SOAPIE progress notes are written by nurses, as well as other members of the health care team.
    • Subjective: This section includes what the patient said, such as,  “I have a headache.” It can also contain information related to pertinent medical history and why the patient is in need of care.
    • Objective: This section contains the observable and measurable data collected during a patient assessment, such as the vital signs, physical examination findings, and lab/diagnostic test results.
    • Assessment: This section contains the interpretation of what was noted in the Subjective and Objective sections, such as a nursing diagnosis in a nursing progress note or the medical diagnosis in a progress note written by a health care provider.
    • Plan: This section outlines the plan of care based on the Assessment section, including goals and planned interventions.
    • Interventions: This section describes the actions implemented.
    • Evaluation: This section describes the patient’s response to interventions and if the planned outcomes were met.

The fifth type of note is the Admission Note:

• This is the first time the nurse meets the patient and can apply the clinical judgement model to facilitate an individualized plan of care. An initial assessment needs to occur rapidly to provide information that is needed by the entire health care team to facilitate the interprofessional treatment plan and health outcomes.

What Is a Nursing Admission Note?

Click on this website for more information on admission notes: nursing-admission-note-5-best-practices-for-facilities

The admission note contains all the pertinent patient information including:  patient demographics, health histories, medications, sexual identification, chief complaint, language used to communicate with, cultural needs and support system. This information is used to create an individualized plan of care that supports the patient’s physical, spiritual, and cultural needs.

Since there is no standard way to write an admission note, documentation can vary depending on the type of facility that a nurse works in.

Nursing Admission Notes: Example Comparison obtained from: Nursing Admission Note: 5 Best Practices for Facilities by Katherine Zheng, PhD, BSN

Bad Example:

“A 67-year-old p/t was admitted with chest pain and shortness of breath, seems alert and oriented. Daughter is currently with the patient.”

In the above example, the admission note very minimally states the patient’s reason for being admitted. It’s difficult to figure out how to tailor a care plan using this information, which is probably also duplicative of what other members of the healthcare team are charting.

Good Example

“67-year-old Asian female patient admitted to ED via ambulance from home with complaints of severe chest pain and shortness of breath. P/t reports a history of hypertension and allergy to shellfish. P/t’s daughter was present upon admission and translating for p/t whose primary language is Korean. Daughter requests interpreter. P/t is A&O x3 with diminished breath sounds in both lung fields. Pulmonary assessment and Q1 vital signs needed.”

The sixth type of note is the Patient Discharge Summary:

• When a patient is discharged from an agency, a discharge summary is documented in the patient record, along with clear verbal and written patient education and instructions provided to the patient. Discharge summary information is frequently provided in a checklist format to ensure accuracy and includes the following:
  • Time of departure and method of transportation out of the hospital (e.g., wheelchair)
  • Name and relationship of the person accompanying the patient at discharge
  • Condition of the patient at discharge
  • Patient education completed and associated educational materials or other information provided to the patient
  • Discharge instructions on medications, treatments, diet, and activity
  • Follow-up appointments or referrals given

The seventh type of documentation is the Minimum Data set (MDS) Charting

Minimum Data Set (MDS) Charting

In long-term care settings, additional documentation is used to provide information for reimbursement by private insurance, Medicare, and Medicaid. The Resident Assessment Instrument Minimum Data Set (MDS) is a federally mandated assessment tool created by registered nurses in skilled nursing facilities to track a patient’s goal achievement, as well as to coordinate the efforts of the health care team to optimize the resident’s quality of care and quality of life. This tool also guides nursing care plan development.

• • Read more details about MDS charting in the Long-Term Care Facility Resident Assessment User Manual established by the Centers for Medicare and Medicaid Services (CMS).
  • Review the information through the link below: (note: the word resident refers to patients )

IV. Another resource is the Guide to documentation for Nurses

The link above gives a great review of what was discussed above, more samples of narrative documentation, samples of documentation flow sheets, and discusses documentation and the state law (Texas). Please remember that each state has a Nursing Board of Licensure which maintains a state-specific Nursing Practice Act.

V. Electronic documentation (EHR) is the main type of documentation

The same rules apply but the medium has changed from paper to computer:

In today’s health care environment, all the information in the prior guide must also be applied to electronic health records management.

The EHR for each patient 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 patient is admitted to the facility. An H&P includes important information about the patient’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 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 patient care. It is helpful for the nurse to review daily progress notes by all team members to ensure continuity of care.

VI. A sample of an electronic health record (EHR) Physical Assessment Document

VI: Learning Activity:

VI.   Citations and Attributions

American Nurses Association. (2010). ANA’s principles for nursing documentation: Guidance for registered nurses. Ethical principles in Nursing

Centers for Medicare & Medicaid Services. (2019, October). Long-term care facility resident assessment instrument (RAI) 3.0 user’s manual. https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf

Chamberlain, M. (2024, November 13). How clinical documentation impacts revenue cycle management. IMO Health. Clinical documentation and reimbursement

College & Association of Registered Nurses of Alberta. (2019, May 21). Discharge teaching [Video]. YouTube. Discharge teaching

HealthIT.gov. (2019, September 10). What is an electronic health record (EHR)? What is an electronic record (EHR)

Healthy Simulation. (2020, July 2). EHR physical assessment document for simulation – Includes Excel template. Documentation for simulation

Hidaje, H. H. (2024). Legal implications of nursing documentation. FDLA Journal, 8, Article 4. Legal implication of nursing documentation

Jefferies, D., Johnson, M., & Griffiths, R. (2010). A meta-study of the essentials of quality nursing documentation. International Journal of Nursing Practice, 16(2), 112–124. Essential aspects of nursing documentation-from a mega study

Okaisu, E. M., Kalikwani, F., Wanyana, G., & Coetzee, M. (2014). Improving the quality of nursing documentation: An action research project. Curationis, 37(2), 1–11. The need to improve nursing documentation

RegisteredNurseRN. (2015a, October 16). Charting for nurses | How to understand a patient’s chart as a nursing student or new nurse [Video]. YouTube. How to understand a patient’s chart as a nursing student

RegisteredNurseRN. (2015b, October 27). FDAR for nurses | How to chart in F-DAR format with examples [Video]. YouTube. The DAR note format

Reiner, G. (n.d.). Defensive documentation: Steps nurses can take to improve their charting and reduce their liability. NSO. Steps nurses can take in their documentation to decrease liability

Tasew, H., Mariye, T., & Teklay, G. (2019). Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia. BMC Research Notes, 12, 612. Nursing documentation practice in public hospitals

Texas Health and Human Services Commission. (2016, September). Documentation by the nurse [PowerPoint]. Documentation by the nurse

Urquhart, C., Currell, R., Grant, M. J., & Hardiker, N. R. (2009). Nursing record systems: Effects on nursing practice and healthcare outcomes. Cochrane Database of Systematic Reviews, (1), 1–66.

Wisconsin Technical College System. (n.d.). Documentation. In Nursing fundamentals (Open RN). Retrieved July 27, 2021, from Documentation in nursing fundamentals