Documentation and SBAR

Documentation and SBAR
Objectives
• Develop strategies for effective communication with the
intediscplanry team using written, verbal, and emerging technology
methods
• Describe the importance of timely, accurate communication in
healthcare
• Identify critical components for safe patient handoff
• List key principles of charting
Communication and • Absent inaccurate or delayed
Patient Care communication can subject the
patient to serious risks or delayed
recovery.
• The Joint Commission identified

critical communication failure as
one of the most common root
causes responsible for sentinel
events.
Patient record
• Communication: Clear, accurate, and up-to-date patient documentation is
a cornerstone for safe care delivery providing flow of information between
providers of care.
• Communicates the plan of care and patient progress to all healthcare team
members.
• Conveys clear picture of patient through different viewpoints and at different times.
• Ensures continuity of care and provides data for evaluation and revision or
continuation of care.
Purposes of the Health Record
• Assessment
• Allows comparison of objective and subjective assessment data gathered by
all team members to determine current health status and progress toward
goals.
• Care planning
• Availability of all assessment data allows nurses to more accurately develop
nursing diagnoses, patient goals, outcome criteria, interventions, and
evaluation criteria for the patient plan of care.
Purposes of the Patient Record #1
• Legal document
• Can be used in court to prove or disprove injuries a patient incurred
unintentionally or to implicate or absolve a healthcare professional with
regard to improper care.
• Quality assurance
• Medical record audits can be performed to determine whether certain
standards of care were met and documented and often lead to changes in
care provision.
• Ongoing quality assurance programs that include audits of patient records are
a part of accreditation requirements.
• Reimbursement
• Provides the basis for decisions regarding care and subsequent
reimbursement to the agency.
• Federal, state, and private payers usually require specific criteria to be met to
cover specific health-related expenses, including diagnostic-related group
(DRG) classification and appropriate related interventions.
Purpose of the Patient Record #4
• Research
• Nursing and healthcare research is often carried out using patient records.
Accurate documentation helps assure that research outcomes are valid and
reliable.
• Education
• Contains valuable educational information that allows students to relate
patient signs and symptoms, interventions, and outcomes.
Principles of Documentation#1
• Confidential
• Keeping information private is a legal and an ethical requirement.
• Applies to written and computerized medical records and any other
information pertaining to the patient’s health status or care.
• The Health Insurance Portability and Accountability Act (HIPAA) regulates all
areas of information management, including security of records.
• Students must de-identify any patient information in written assignments to
be HIPAA compliant.
Principles of Documentation#2
• Accurate
• Nursing documentation should only contain observations that nurses have
seen, heard, smelled, or felt. Observations or statements by other healthcare
professionals need to be identified as such.
• All information that was charted remains in the patient record; erasure is not
permissible.
• Proofreading should be done to assure correct spelling and correct use of
medical terms.
Principles of Documentation #3
• Concise and complete
• Partial sentences and phrases should be used in narratives.
• The patient’s name and terms referring to the patient can be eliminated in
narrative charting.
• Only abbreviations that are commonly accepted and approved by the

institution should be used.
• Objective
• Using direct quotes of patient statements can help maintain objectivity,
especially when documenting psychosocial and mental health issues.
• Actual patient behavior should be described rather than making

interpretations.
• Organized and timely
• Information should be documented chronologically and include patient
response to interventions.
• Timely documentation decreases the chance of forgetting important

information.
• All medications and procedures should be documented upon completion.

Universal Computer-Based Patient Record#1
• Federally initiated goal of having a single health-related electronic
record for all individuals.
• Would allow patients to share their complete health information with
any practitioner, regardless of institutional affiliation or location.
• Supported by the 2009 Health Information Technology for Economic
and Clinical Health (HITECH) Act whose goal it is to increase patients’
access to their own medical records.
Universal Computer-Based Patient Record #2
• Clinical surveillance tools
• Automated surveillance tools that scan electronic health record data and
produce a real-time patient’s risk score for designated high-risk conditions.
• Handheld devices
• Smartphone and tablets allow bedside access to such supports as drug
information, assessment tools, conversion tables, immunization guidelines,
language translation, and access to evidence to support clinical decisions.
Universal Computer-Based Patient
Record (CPR) #3
• Standardized vocabulary
• Important for use in the electronic health record, as consistency of
terminology makes retrieval of individual and aggregate data possible.
• The ANA has approved the following as appropriate for nursing practice:
Omaha, Nursing Interventions Classification (NIC), Nursing Outcomes
Classification (NOC), Home Health Care Classification (HHCC), NANDA-I, and
Ozbolt’s Patient Care Data Set (PCDS).
Types of Nursing Entries #1
• Kardex
• Admission Entries
• Narrative notes
• Charting by Exception
• Progress Notes
• SOAP and SOAPIER notes
• PIE and APIE notes
• FOCUS DAR notes
• Flow sheets: Tables with vertical and horizontal columns allowing for
documentation of routine assessments and procedures.
• Plan of care: Contains nursing diagnoses, goals, outcome criteria,
interventions, and evaluation. Standardized plans of care may be
used, but must always be individualized.
• Critical pathways: Multidisciplinary tools that identify expected
progression of patients toward discharge. Often used for patients
requiring complex care or for frequently encountered situations.
• Written Handoff Summary
• Nursing Discharge Summary
• Medication Administration Record (MAR)
• Home Care Documentation
• Long-Term Care Documentation
• Incident Report
Template for Communication
• SBAR
• Situation: What is happening at the present time?
• Background: What are the circumstances leading up to this situation?
• Assessment: What is the problem?
• Recommendations: What should be done to correct the problem?
Reporting to the Primary
Healthcare Provider/Healthcare Team
• Telephone communication
• Verbal Orders
• Consults
• Rounding
• Care Plan Conferences
• Voice Communication Badges
TeamSTEPPS
• An acronym for Team Strategies and Tools to Enhance Performance
and Patient Safety.
• A safety curriculum designed to improve patient outcomes by

cultivating teamwork among healthcare providers.
• Developed in 2006 by the U.S. Department of Defense (DOD) Patient

Safety Program and the Agency for Healthcare Research and Quality
(AHRQ).
TeamSTEPPS Communication Tools
and Strategies
• SBAR
• Call-out
• Check-back
• Handoff
• I PASS THE BATON
• CUS (I am concerned; I am uncomfortable; this is a Safety Issue)
References
• Craven, R., Hirnle, C., & Henshaw, C. M. (2021). Craven, Hirnle, &
Henshaw: Fundamentals of nursing (9th ed.). Wolters Kluwer.

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Documentation and SBAR

• The Joint Commission identified

• Only abbreviations that are commonly accepted and approved by the

• Actual patient behavior should be described rather than making

• Timely documentation decreases the chance of forgetting important

• All medications and procedures should be documented upon completion.

• A safety curriculum designed to improve patient outcomes by

• Developed in 2006 by the U.S. Department of Defense (DOD) Patient

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