1. Licensure, Regulations & Standards
Open Resources for Nursing (Open RN) and Amy Ertwine
Standards for nursing care are set by several organizations, including state Nurse Practice Acts, the American Nurses Association (ANA), agency policies and procedures, federal regulators, and other professional nursing organizations. These standards promote guidelines for safe, competent care to be provided to the public.
Nurse Practice Act
Nurses must legally follow regulations set by the Nurse Practice Act (NPA) in the state in which they work. The Nurse Practice Act is enacted by that state’s legislature, defines the scope of practice for nurses in that state, and establishes regulations for nursing practice. If nurses do not follow the standards and scope of practice set forth by the Nurse Practice Act, they can have their nursing license revoked by the state Board of Nursing. The Board of Nursing is a licensing and regulatory body that issues nursing licenses to qualified candidates and also provides discipline for nurses who do not follow standards and scope of practice established in the Nurse Practice Act.
Nursing students must understand their scope of practice as outlined in the Nurse Practice Act in the state in which they are completing their clinical courses. Nursing students are legally accountable for the quality of care they provide to clients just as nurses are accountable. Students are expected to recognize the limits of their knowledge and experience and appropriately alert faculty or other authority figures regarding situations that are beyond their competency. A violation of the standards of practice constitutes unprofessional conduct and can result in the Board of Nursing denying a license to a nursing graduate.
American Nurses Association (ANA)
The American Nurses Association (ANA) is a national, professional nursing organization that was established in 1896. The ANA represents the interests of nurses in all 50 states of America while also promoting improved health care for everyone. The mission of the ANA is to “lead the profession to shape the future of nursing and health care.”[1] The ANA states that it exists to advance the nursing profession by doing the following:
- Fostering high standards of nursing practice
- Promoting a safe and ethical work environment
- Bolstering the health and wellness of nurses
- Advocating on health care issues that affect nurses and the public[2]
Read more information about the American Nurses Association.
View the Discover the American Nurses Association video.[3]
ANA Scope and Standards of Practice
The American Nurses Association (ANA) publishes two resources that set standards and guide professional nursing practice in the United States: The Code of Ethics for Nurses and Nursing: Scope and Standards of Practice. The Code of Ethics for Nurses establishes an ethical framework for nursing practice across all roles, levels, and settings. It is discussed in greater detail in the “Legal and Ethical Considerations” section of this chapter. The Nursing: Scope and Standards of Practice describes a professional nurse’s scope of practice and defines the who, what, where, when, why, and how of nursing. It also sets 18 standards of professional practice that all registered nurses are expected to perform competently.[4]
The “who” of nursing practice are the nurses who have been educated, titled, and maintain active licensure to practice nursing. The “what” of nursing is the recently revised definition of nursing: “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.”[5] Simply put, nurses treat human responses to health problems and life processes and advocate for the care of others.
Nursing practice occurs “when” there is a need for nursing knowledge, wisdom, caring, leadership, practice, or education, anytime, anywhere. Nursing practice occurs in any environment “where” there is a health care consumer in need of care, information, or advocacy. The “why” of nursing practice is described as nursing’s response to the changing needs of society to achieve positive health care consumer outcomes in keeping with nursing’s social contract and obligation to society. The “how” of nursing practice is defined as the ways, means, methods, and manners that nurses use to practice professionally.[6] The “how” of nursing is further defined by the standards of practice set by the ANA. There are two sets of standards, the Standards of Professional Nursing Practice and the Standards of Professional Performance.
The ANA Standards of Professional Nursing Practice are “authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.”[7] These standards define a competent level of nursing practice based on the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.[8] Each of these standards is further discussed in the “Nursing Process” chapter of this book.
The ANA Standards of Professional Performance are 12 additional standards that describe a nurse’s professional behavior, including activities related to ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice evaluation, resource stewardship, and environmental health. All registered nurses are expected to engage in these professional role activities based on their level of education, position, and role. Registered nurses are accountable for their professional behaviors to themselves, health care consumers, peers, and ultimately to society.[9] The 2021 Standards of Professional Performance are as follows:
- Ethics. The registered nurse integrates ethics in all aspects of practice.
- Advocacy. The registered nurse demonstrates advocacy in all roles and settings.
- Respectful and Equitable Practice. The registered nurse practices with cultural humility and inclusiveness.
- Communication. The registered nurse communicates effectively in all areas of professional practice.
- Collaboration. The registered nurse collaborates with the health care consumer and other key stakeholders.
- Leadership. The registered nurse leads within the profession and practice setting.
- Education. The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking.
- Scholarly Inquiry. The registered nurse integrates scholarship, evidence, and research findings into practice.
- Quality of Practice. The registered nurse contributes to quality nursing practice.
- Professional Practice Evaluation. The registered nurse evaluates one’s own and others’ nursing practice.
- Resource Stewardship. The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and judiciously used.
- Environmental Health. The registered nurse practices in a manner that advances environmental safety and health.[10]
Years ago, nurses were required to recite the Nightingale pledge to publicly confirm their commitment to maintain the profession’s high ethical and moral values: “I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and family affairs coming to my knowledge in the practice of my calling, with loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care.” Although some of the words are outdated, the meaning is clear: Nursing is a calling, not just a job; to answer that call, nurses must be dedicated to serve their community according to the ANA standards of care and code of ethics.[11]
Employer Policies, Procedures, and Protocols
In addition to professional nursing standards set by the American Nurses Association and the state Nurse Practice Act where they work, nurses and nursing students must also practice according to agency policies, procedures, and protocols. For example, hospitals often set a policy that requires a thorough skin assessment must be completed and documented daily on every client. If a nurse did not follow this policy and a client developed a pressure injury, the nurse could be held liable. In addition, every agency has their own set of procedures and protocols that a nurse and nursing student must follow. For example, each agency has specific procedural steps for performing nursing skills, such as inserting urinary catheters. A protocol is defined by the Wisconsin Nurse Practice Act as a “precise and detailed written plan for a regimen of therapy.” For example, agencies typically have a hypoglycemia protocol that nurses automatically implement when a client’s blood sugar falls below a specific number. The hypoglycemia protocol includes actions such as providing orange juice and rechecking the blood sugar. These agency-specific policies, procedures, and protocols supersede the information taught in nursing school, and nurses and nursing students can be held legally liable if they don’t follow them. Therefore, it is vital for nurses and nursing students to always review and follow current agency-specific procedures, policies, and protocols when providing client care.
Nurses and nursing students must continue to follow their scope of practice as defined by the Nurse Practice Act in the state they are practicing when following agency policies, procedures, and protocols. Situations have occurred when a nurse or nursing student was asked by an agency to do something outside their defined scope of practice that impaired their nursing license. It is always up to you to protect your nursing license and follow the state’s Nurse Practice Act when providing client care.
Federal Regulations
In addition to nursing scope of practice and standards being defined by state Nurse Practice Acts, the American Nurses Association, and employer policies, procedures, and protocols, nursing practice is also influenced by federal regulations enacted by agencies such as The Joint Commission and the Centers for Medicare and Medicaid.
The Joint Commission
The Joint Commission is a national organization that accredits and certifies over 20,000 health care organizations in the United States. The mission of The Joint Commission (TJC) is to continuously improve health care for the public by inspiring health care organizations to excel in providing safe and effective care of the highest quality and value.[12] The Joint Commission sets standards for providing safe, high-quality health care. Examples of standards include following National Patient Safety Goals and establishing a Safety Culture in health care agencies.
National Patient Safety Goals
The Joint Commission establishes annual National Patient Safety Goals for various types of agencies based on data regarding current national safety concerns.[13] For example, National Patient Safety Goals for hospitals include the following:
- Identify Patients Correctly
- Improve Staff Communication
- Use Medicines Safely
- Use Alarms Safely
- Prevent Infection
- Identify Patient Safety Risks
- Prevent Mistakes in Surgery
Nurses, nursing students, and other staff members are expected to incorporate actions related to these safety goals into their daily client care. For example, SBAR (Situation, Background, Assessment, and Recommendation) handoff reporting techniques, barcode scanning equipment, and perioperative team “time-outs” prior to surgery are examples of actions incorporated at agencies based on National Patient Safety Goals. Nursing programs also use National Patient Safety Goals to guide their curriculum and clinical practice expectations. National Patient Safety Goals are further discussed in the “Safety” chapter of this book.
Use the information provided below to read more about The Joint Commission and National Patient Safety Goals.
Safety Culture
A safety culture empowers nurses, nursing students, and other staff members to speak up about their concerns about client risks and to report errors and near misses, all of which drive improvement in client care and reduce the incidences of client harm.[14] Many health care agencies have implemented a safety culture in their workplace and successfully reduced incidences of client harm. An example of a safety culture action is a nurse or nursing student creating an incident report when an error occurs when administering medication. The incident report is used by the agency to investigate system factors that contribute to errors. To read more about how The Joint Commission encourages agencies create a safety culture, use the information provided in the following box.
Read more about Safety Culture from The Joint Commission.
Reimbursement for Health Services and Regulations
Although many individuals pursue nursing careers to help others, it is important to realize that health care is a business. Even non-profit organizations rely on funding to provide services, pay employees, and maintain the facility and equipment. There are several sources of funding for health care, including private health insurance or government-funded programs like Medicare and Medicaid. No matter what type of funding source, agencies must comply with state and federal regulations.
Private Health Insurance
The health insurance industry provides private health insurance that is sponsored by employers or purchased privately by individuals from the Health Insurance Marketplace. Private insurance programs must comply with state and federal regulations even though they are privately owned. Read more about the Affordable Care Act in the following box.
Affordable Care Act
The Affordable Care Act (ACA) of 2010, commonly referred to as “Obamacare,” created cost-reduction programs for private insurance through a public insurance marketplace. Insurance premiums are subsidized by taxpayer funds to help reduce the cost of health insurance and make it more affordable. Subsidies are provided for incomes between 100% and 400% of the federal poverty level. For example, in 2023, the income range for a family of four was $30,000 to $120,000.[15] These subsidies have significantly decreased the number of uninsured individuals, but unfortunately, insurance premiums sold through the marketplace can still be high. Approximately 7.7% of individuals and families in the United States remain uninsured, resulting in increased health risks due to lack of participation in preventive services, well child care, dental care, and treatment of chronic disease. As a result, visits to the Emergency Room often increase when clients delay care due to cost concerns, further contributing to the cost of health care as hospitals are often not reimbursed for these visits.[16],[17]
Federal and State-Funded Health Care
Medicare is federally funded health care coverage of individuals aged 65 or older, individuals younger than 65 with certain disabilities, or those at any age with end-stage renal disease. Medicaid is a combination of state and federally funded health care coverage of low-income adults, pregnant women, and children. Agencies receiving Medicare or Medicaid reimbursement must comply with state and federal regulations and meet established client outcomes, or their reimbursement rates are decreased or eliminated. Read more about Medicare in the following box.
Medicare
Medicare uses a system of reimbursement based on diagnosis-related groups (DRGs). DRGs classify clients with similar clinical characteristics, such as age, gender, severity of disease, and comorbidities, with the rationale that these clients have similar care needs. Based on these DRGs, reimbursement occurs at rates set by the Centers for Medicare & Medicaid Services (CMS) for qualifying services. Differences between set reimbursement rates and health care organization charges cannot be passed on to the individual, although the individuals may be required to pay copays for care received. By agreeing to accept clients with Medicare or Medicaid coverage, the health care organization agrees to accept these rates of reimbursement, although they may be less than the actual cost of providing care. For example, in 2017, Medicaid reimbursement was 89% of the cost of providing care.[18],[19],[20]
Centers for Medicare & Medicaid Services
The Centers for Medicare & Medicaid Services (CMS) is a federal agency that establishes and enforces regulations to protect client safety in hospitals that receive Medicare and Medicaid funding. For example, one CMS regulation states that a hospital’s policies and procedures must require confirmation of specific information before medication is administered to clients. This CMS regulation is often referred to as “checking the rights of medication administration.” You can read more information about checking the rights of medication administration in the “Administration of Enteral Medications” chapter of the Open RN Nursing Skills, 2e textbook.[21]
CMS also enforces quality standards in health care organizations that receive Medicare and Medicaid funding. These organizations are reimbursed based on the quality of their client outcomes. For example, organizations with high rates of healthcare-associated infections (HAI) receive less reimbursement for services they provide. As a result, many agencies have reexamined their policies, procedures, and protocols to promote optimal client outcomes and maximum reimbursement.
Now that we have discussed various agencies that affect a nurse’s scope and standards of practice, let’s review various types of health care settings where nurses work and members of the health care team.
- American Nurses Association. (n.d.). About ANA. https://www.nursingworld.org/ana/about-ana/ ↵
- American Nurses Association. (n.d.). About ANA. https://www.nursingworld.org/ana/about-ana/ ↵
- American Nurses Association. (2010, May 14). Discover the American Nurses Association (ANA). [Video]. YouTube. All rights reserved. https://youtu.be/PRwPhOjeqL4 ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- Bostain, L. (2020, June 25). Nursing professionalism begins with you. American Nurse. https://www.myamericannurse.com/nursing-professionalism-begins-with-you/ ↵
- The Joint Commission. (n.d.). https://www.jointcommission.org/ ↵
- The Joint Commission. (n.d.). National patient safety goals. https://www.jointcommission.org/standards/national-patient-safety-goals/ ↵
- Joint Commission Center for Transforming Healthcare. (n.d.). Creating a safety culture. https://www.centerfortransforminghealthcare.org/why-work-with-us/video-resources/creating-a-safety-culture ↵
- HealthCare.gov. (n.d.). Glossary. ↵
- Assistant Secretary for Planning and Evalution. (2023). National Uninsured Rate Reaches an All-Time Low in Early 2023 After the Close of the ACA Open Enrollment Period ↵
- U.S. Department of Health and Human Services. (2030). Healthy People 2030. Access to Health Services. ↵
- Chen, Y. J., Zhang, X. Y., Yan, J. Q., Xue-Tang, Qian, M. C., & Ying X. H. (2023) Impact of diagnosis-related groups on inpatient quality of health care: A systematic review and meta-analysis. Inquiry. 2023 Jan-Dec; 60, 469580231167011. https://doi.org/10.1177/00469580231167011. ↵
- U.S. Centers for Medicare and Medicaid. (n.d.). CMS.gov ↵
- Wisconsin Hospital Association. (2024). Health Topics: Medicaid ↵
- This work is a derivative of Nursing Skills, 2e by Open RN and is licensed under CC BY 4.0 ↵
Client Scenario
Mr. Hernandez is a 47-year-old client admitted to the neurological trauma floor as the result of a motor vehicle accident two days ago. The client sustained significant facial trauma in the accident and his jaw is wired shut. His left eye is currently swollen, and he has significant bruising to the left side of his face. The nurse completes a visual assessment and notes that the client has normal extraocular movement, peripheral vision, and pupillary constriction bilaterally. Additional assessment reveals that Mr. Hernandez also sustained a fracture of the left arm and wrist during the accident. His left arm is currently in a cast and sling. He has normal movement and sensation with his right hand. Mrs. Hernandez is present at the client’s bedside and has provided additional information about the client. She reports that Mr. Hernandez’s primary language is Spanish but that he understands English well. He has a bachelor’s degree in accounting and owns his own accounting firm. He has a history of elevated blood pressure but is otherwise healthy.
The nurse notes that the client’s jaw is wired, and he is unable to offer a verbal response. He does understand English well, has appropriate visual acuity, and is able to move his right hand and arm.
Based on the assessment information that has been gathered, the nurse plans several actions to enhance communication. Adaptive communication devices such as communication boards, symbol cards, or electronic messaging systems will be provided. The nurse will eliminate distractions such as television and hallway noise to decrease sources of additional stimuli in the communication experience.
Sample Documentation Using a Summary Note:
6/01/2024, 1615: Mr. Hernandez has impaired verbal communication due to facial fracture and inability to enunciate words around his wired jaw. He understands both verbal and written communication. Mr. Hernandez has left sided facial swelling, but no visual impairment. He has a left arm fracture but is able to move and write with his right hand. The client is supplied with communication cards and marker board. He responds appropriately with written communication and is able to signal his needs. - J. Smith, RN
Client Scenario
Mr. Hernandez is a 47-year-old client admitted to the neurological trauma floor as the result of a motor vehicle accident two days ago. The client sustained significant facial trauma in the accident and his jaw is wired shut. His left eye is currently swollen, and he has significant bruising to the left side of his face. The nurse completes a visual assessment and notes that the client has normal extraocular movement, peripheral vision, and pupillary constriction bilaterally. Additional assessment reveals that Mr. Hernandez also sustained a fracture of the left arm and wrist during the accident. His left arm is currently in a cast and sling. He has normal movement and sensation with his right hand. Mrs. Hernandez is present at the client’s bedside and has provided additional information about the client. She reports that Mr. Hernandez’s primary language is Spanish but that he understands English well. He has a bachelor’s degree in accounting and owns his own accounting firm. He has a history of elevated blood pressure but is otherwise healthy.
The nurse notes that the client’s jaw is wired, and he is unable to offer a verbal response. He does understand English well, has appropriate visual acuity, and is able to move his right hand and arm.
Based on the assessment information that has been gathered, the nurse plans several actions to enhance communication. Adaptive communication devices such as communication boards, symbol cards, or electronic messaging systems will be provided. The nurse will eliminate distractions such as television and hallway noise to decrease sources of additional stimuli in the communication experience.
Sample Documentation Using a Summary Note:
6/01/2024, 1615: Mr. Hernandez has impaired verbal communication due to facial fracture and inability to enunciate words around his wired jaw. He understands both verbal and written communication. Mr. Hernandez has left sided facial swelling, but no visual impairment. He has a left arm fracture but is able to move and write with his right hand. The client is supplied with communication cards and marker board. He responds appropriately with written communication and is able to signal his needs. - J. Smith, 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 personally assessed, observed, or performed.
- Proper medical terminology, grammar, and spelling should be used.
- All types of documentation must include the date, time, and signature of the person documenting.
- Abbreviations should be avoided in legal documentation.
- Documentation must be completed in an accurate and timely manner after the task is performed. Do not document in advance of completing a task.
- Assessments, interventions, medications, or treatments that were not completed should never be charted as completed. This is considered falsification and can present serious legal ramifications for the nurse and the health care facility.
- When using paper documentation, avoid leaving blank lines to prevent others from adding to your documentation. In the event of a charting error, draw a single line through the error and write, "mistaken entry" above the line with your initials. Errors should never be erased, scribbled out, or covered with white-out.
- If electronic documentation is charted in error, it should be corrected with the details of the error and the correction noted in the background should the need arise to review the documentation.
Documentation is used for many purposes. It is used to ensure continuity of care across health care team members and across shifts; monitor standards of care for quality assurance activities; and provide information for reimbursement purposes by insurance companies, Medicare, and Medicaid. Documentation may also be used for research purposes or, in some instances, for legal concerns in a court of law.
Documentation by nurses includes recording client assessments, writing progress notes, and creating or addressing information included in nursing care plans. Nursing care plans are further discussed in the "Planning" section of the “Nursing Process” chapter.
Common Types of Documentation
Common formats used to document client care include charting by exception, focused DAR notes, narrative notes, SOAPIE progress notes, client discharge summaries, and Minimum Data Set (MDS) charting.
Charting by Exception
Charting by exception (CBE) documentation was designed to decrease the amount of time required to document care. CBE contains a list of normal findings. After performing an assessment, nurses confirm normal findings on the list found on assessment and write only brief progress notes for abnormal findings or to document communication with other team members.
Focused DAR Notes
Focused DAR notes are a type of progress note that are commonly used in combination with charting by exception documentation. DAR stands for Data, Action, and Response. Focused DAR notes are brief. Each note is focused on one client problem for efficiency in documenting and reading.
- Data: This section contains information collected during the client assessment, including vital signs and physical examination findings found during the “Assessment” phase of the nursing process. The Assessment phase is further discussed in the “Nursing Process” chapter. Think of the "Data" section as describing the main problem.
- Action: This section contains the nursing actions that are planned and implemented for the client’s focused problem. This section correlates to the “Planning” and “Implementation” phases of the nursing process and are further discussed in the “Nursing Process” chapter. Think of the "Action" section as describing what was done about the problem.
- Response: This section contains information about the client’s response to the nursing actions and evaluates if the planned care was effective. This section correlates to the “Evaluation” phase of the nursing process that is further discussed in the “Nursing Process” chapter. Think of the "Response" section as describing the result of what happened after performing the actions.
Sample DAR Note
Refer back to the "ISBARR" example provided in a box in Chapter 2.4. The nurse would document the associated provider notification in the EHR using a DAR note:
D: Client reports increasing pain at the incisional site, rated as 7/10, increased from 4/10 despite receiving oral Vicodin 5/325 at 1030. Vital Signs: BP 160/95, HR 90, RR 22, O2 sat 96%, and temperature 38 degrees C. There is 4 cm of redness surrounding the incision that is warm and tender to touch with moderate serosanguinous drainage. Lung sounds are clear, and HR is regular.
A: Dr. Smith was notified at 1210 and orders received for CBC STAT and increased Vicodin dose to 10/325 mg.
R: Lab results pending. Additional Vicodin administered per order at 1215. At 1315, client reported decreased pain level of 3/10. Will notify provider of results when they become available. -J. White, RN
View sample charting by exception paper documentation with associated DAR notes for abnormal findings.
For more information about writing DAR notes, visit What is F-DAR Charting?
View a video explaining F-DAR charting.[4]
Narrative Notes
Narrative notes, also called summary notes, are a type of progress note that chronicles assessment findings and nursing activities for the client that occurred throughout the entire shift or visit. View sample narrative note documentation for body system assessments in the Open RN Nursing Skills, 2e textbook.
Sample Cardiac Narrative Note
Client denies chest pain or shortness of breath. Vital signs are within normal limits. Point of maximum impulse palpable at the fifth intercostal space of the midclavicular line. No lifts, heaves, or thrills identified on inspection or palpation. JVD absent. S1 and S2 heart sounds in regular rhythm with no murmurs or extra sounds. Skin is warm, pink, and dry. Capillary refill is less than two seconds. Color, movement, and sensation are intact in upper and lower extremities. Peripheral pulses are present (+2) and equal bilaterally. No peripheral edema is noted. Hair is distributed evenly on lower extremities.
SOAPIE Notes
SOAPIE is a mnemonic for a type of progress note that is organized by 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 client said, such as, “I have a headache.” It can also contain information related to pertinent medical history and why the client is in need of care.
- Objective: This section contains the observable and measurable data collected during a client 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 client response to interventions and if the planned outcomes were met.
Sample SOAPIE Note
Here is an example of SOAPIE note with the same information previously discussed in the box describing a sample DAR note.
S: Client reports having incisional pain of 6/10, increased from 4/10 despite receiving oral Vicodin 5/325 at 1030.
O: Vital Signs: BP 160/95, HR 90, RR 22, O2 sat 96%, and temperature 38 degrees C. There is 4 cm of redness surrounding the incision that is warm and tender to touch with moderate serosanguinous drainage. Lung sounds are clear, and HR is regular.
A: Dr. Smith was notified at 1210.
P: New orders received for CBC STAT to check for infection and increased Vicodin dose to 10/325 mg for pain management.
I: Additional Vicodin administered per order at 1215.
E: At 1315, client reported decreased pain level of 3/10. Will notify provider of results when they become available. -J. White, RN
Discharge Summary
When a client is discharged from an agency, a discharge summary is documented in the client record, along with clear verbal and written client education and instructions provided to the client. 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 person accompanying the client at discharge
- Condition of the client at discharge
- Client education completed and associated educational materials or other information provided to the client
- Discharge instructions on medications, treatments, diet, and activity
- Follow-up appointments or referrals given
See Figure 2.12[5] for an image of a nurse providing discharge instructions to a client. Discharge teaching typically starts at admission and continues throughout the client's stay because this allows for reinforcement of teaching topics.
Sample Discharge Summary Note
Client discharged home at 1645 with Sarah Jones, his wife, in a wheelchair to their car. Client was in stable condition with the following vital signs: BP 124/76, HR 76, RR 16, O2 sat 98%. Dressing over surgical incision site was dry and intact. Client education was provided on wound care at home and the "Caring for Your Incision" handout was provided. The Discharge Instructions sheet was reviewed with orders for a regular diet and no heavy lifting until follow-up appointment with Dr. Singer on 8/26/2024. Referral completed with ACME Home Health for wound care with the initial home visit scheduled for tomorrow.
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 client’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.[6] This tool also guides nursing care plan development.
Incident Reports
Incident reports, also called variance reports, are a specific type of documentation that is completed when there is an unexpected occurrence, such as a medication error, client injury, client fall, or a near miss, where an error did not actually occur, but was prevented from occurring. Refer to agency policies for specific events requiring incident reports.
Incident reports are completed by the staff member involved in the occurrence. Documentation includes the date and time of the event, client involved (if applicable), what occurred, what was done in response to the event, what else was happening at the time the incident occurred, as well as other facility specific required data. Abbreviations, assumptions, or interpretations should be avoided.
Incident reports are intended to be used as a safety tool to identify system issues and process problems that could benefit from quality and safety improvements. Incident reports should be used as component of a safety culture, not punitively. If used punitively, staff become reluctant to report errors or suggest process improvements for fear of “getting in trouble.”
Incident reports are not a part of the medical record and should not be mentioned in the medical record. However, the specific event should be documented in the medical record, along with health care provider notification and interventions provided.[7]
Read additional information about Incident Reports on the NSO website.
Active listening: Process by which we are communicating verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with the speaker. (Chapter 2.3)
Aphasia: A communication disorder that results from damage to portions of the brain that are responsible for language. (Chapter 2.3)
Assertive communication: A way to convey information that describes the facts, the sender’s feelings, and explanations without disrespecting the receiver’s feelings. This communication is often described as using “I” messages: “I feel…,” “I understand…,” or “Help me to understand…” (Chapter 2.2)
Bedside handoff report: A handoff report in hospitals that involves clients, their family members, and both the off-going and the incoming nurses. The report is performed face to face and conducted at the client's bedside. (Chapter 2.4)
Broca's aphasia: A type of aphasia where clients understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. People with Broca's aphasia typically understand the speech of others fairly well. Because of this, they are often aware of their difficulties and can become easily frustrated. (Chapter 2.3)
Charting by exception (CBE): A type of documentation where a list of “normal findings” is provided and nurses document assessment findings by confirming normal findings and writing brief documentation notes for any abnormal findings. (Chapter 2.5)
DAR: A type of documentation often used in combination with charting by exception. DAR stands for Data, Action, and Response. Focused DAR notes are brief, and each note is focused on one client problem for efficiency in documenting, as well as for reading. (Chapter 2.5)
Electronic Health Record (EHR): A digital version of a client’s paper chart. EHRs are real-time, client-centered records that make information available instantly and securely to authorized users. (Chapter 2.5)
Expressive aphasia: A type of aphasia where the client has difficulty putting thoughts into words. The client may cognitively know what they want to say but are unable to express their thoughts. (Chapter 1.4, Chapter 2.3)
Global aphasia: A type of aphasia that results from damage to extensive portions of the language areas of the brain. Individuals with global aphasia have severe communication difficulties and may be extremely limited in their ability to speak or comprehend language. They may be unable to say even a few words or may repeat the same words or phrases over and over again. They may have trouble understanding even simple words and sentences. (Chapter 2.3)
Handoff report: A process of exchanging vital client information, responsibility, and accountability between the off-going and incoming nurses in an effort to ensure safe continuity of care and the delivery of best clinical practices. (Chapter 2.4)
Health Insurance Portability and Accountability Act (HIPAA): Standards for ensuring privacy of client information that are enforceable by law. (Chapter 2.3)
Incident reports: Also called variance reports, incident reports are a specific type of documentation that is completed when there is an unexpected occurrence, such as a medication error, client injury, or client fall, or a near miss, where an error did not actually occur, but was prevented from occurring. (Chapter 2.5)
ISBARR: A mnemonic for the format of professional communication among health care team members that includes Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back. (Chapter 2.4)
Minimum Data Set (MDS): A federally mandated assessment tool used in skilled nursing facilities to track a client’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. (Chapter 2.5)
Narrative note: A type of documentation that chronicles all of the client’s assessment findings and nursing activities that occurred throughout the shift. (Chapter 2.5)
Nontherapeutic responses: Responses to clients that block communication, expression of emotion, or problem-solving. (Chapter 2.3)
Nonverbal communication: Facial expressions, tone of voice, pace of the conversation, and body language. (Chapter 2.2)
Progressive relaxation: Types of relaxation techniques that focus on reducing muscle tension and using mental imagery to induce calmness. (Chapter 2.2)
Receptive aphasia: A type of aphasia where the client has difficulty in understanding what is being communicated to them. The client may be able to verbalize their thoughts and feelings but does not understand what is spoken to them. (Chapter 2.3)
Relaxation breathing: A breathing technique used to reduce anxiety and control the stress response. (Chapter 2.2)
SOAPIE: A mnemonic for a type of documentation that is organized by six categories: Subjective, Objective, Assessment, Plan, Interventions, and Evaluation. (Chapter 2.5)
Therapeutic communication: The purposeful, interpersonal information transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills, which leads to client understanding and participation. (Chapter 2.3)
Therapeutic communication techniques: Techniques that encourage clients to explore feelings, problem solve, and cope with responses to medical conditions and life events. (Chapter 2.3)
Verbal communication: Exchange of information using words understood by the receiver. (Chapter 2.2)
Active listening: Process by which we are communicating verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with the speaker. (Chapter 2.3)
Aphasia: A communication disorder that results from damage to portions of the brain that are responsible for language. (Chapter 2.3)
Assertive communication: A way to convey information that describes the facts, the sender’s feelings, and explanations without disrespecting the receiver’s feelings. This communication is often described as using “I” messages: “I feel…,” “I understand…,” or “Help me to understand…” (Chapter 2.2)
Bedside handoff report: A handoff report in hospitals that involves clients, their family members, and both the off-going and the incoming nurses. The report is performed face to face and conducted at the client's bedside. (Chapter 2.4)
Broca's aphasia: A type of aphasia where clients understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. People with Broca's aphasia typically understand the speech of others fairly well. Because of this, they are often aware of their difficulties and can become easily frustrated. (Chapter 2.3)
Charting by exception (CBE): A type of documentation where a list of “normal findings” is provided and nurses document assessment findings by confirming normal findings and writing brief documentation notes for any abnormal findings. (Chapter 2.5)
DAR: A type of documentation often used in combination with charting by exception. DAR stands for Data, Action, and Response. Focused DAR notes are brief, and each note is focused on one client problem for efficiency in documenting, as well as for reading. (Chapter 2.5)
Electronic Health Record (EHR): A digital version of a client’s paper chart. EHRs are real-time, client-centered records that make information available instantly and securely to authorized users. (Chapter 2.5)
Expressive aphasia: A type of aphasia where the client has difficulty putting thoughts into words. The client may cognitively know what they want to say but are unable to express their thoughts. (Chapter 1.4, Chapter 2.3)
Global aphasia: A type of aphasia that results from damage to extensive portions of the language areas of the brain. Individuals with global aphasia have severe communication difficulties and may be extremely limited in their ability to speak or comprehend language. They may be unable to say even a few words or may repeat the same words or phrases over and over again. They may have trouble understanding even simple words and sentences. (Chapter 2.3)
Handoff report: A process of exchanging vital client information, responsibility, and accountability between the off-going and incoming nurses in an effort to ensure safe continuity of care and the delivery of best clinical practices. (Chapter 2.4)
Health Insurance Portability and Accountability Act (HIPAA): Standards for ensuring privacy of client information that are enforceable by law. (Chapter 2.3)
Incident reports: Also called variance reports, incident reports are a specific type of documentation that is completed when there is an unexpected occurrence, such as a medication error, client injury, or client fall, or a near miss, where an error did not actually occur, but was prevented from occurring. (Chapter 2.5)
ISBARR: A mnemonic for the format of professional communication among health care team members that includes Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back. (Chapter 2.4)
Minimum Data Set (MDS): A federally mandated assessment tool used in skilled nursing facilities to track a client’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. (Chapter 2.5)
Narrative note: A type of documentation that chronicles all of the client’s assessment findings and nursing activities that occurred throughout the shift. (Chapter 2.5)
Nontherapeutic responses: Responses to clients that block communication, expression of emotion, or problem-solving. (Chapter 2.3)
Nonverbal communication: Facial expressions, tone of voice, pace of the conversation, and body language. (Chapter 2.2)
Progressive relaxation: Types of relaxation techniques that focus on reducing muscle tension and using mental imagery to induce calmness. (Chapter 2.2)
Receptive aphasia: A type of aphasia where the client has difficulty in understanding what is being communicated to them. The client may be able to verbalize their thoughts and feelings but does not understand what is spoken to them. (Chapter 2.3)
Relaxation breathing: A breathing technique used to reduce anxiety and control the stress response. (Chapter 2.2)
SOAPIE: A mnemonic for a type of documentation that is organized by six categories: Subjective, Objective, Assessment, Plan, Interventions, and Evaluation. (Chapter 2.5)
Therapeutic communication: The purposeful, interpersonal information transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills, which leads to client understanding and participation. (Chapter 2.3)
Therapeutic communication techniques: Techniques that encourage clients to explore feelings, problem solve, and cope with responses to medical conditions and life events. (Chapter 2.3)
Verbal communication: Exchange of information using words understood by the receiver. (Chapter 2.2)
