Documentation

NUR101
Lecture #5
Fall 2008

K. Burger, MSED, MSN, RN, CNE

PPP by S. Niggemeier, MSN, BSN, RN

Purpose of Documentation

Supports Nsg
actions indicates
clients condition
Primary
communication
tool
Legal protection
Reimbursement

Education
Quality
Assurance
Research
Historic and
legal document
Decision analysis

Types of Documentation

Nurses Notes
Flow sheets
Graphics
Nursing Care Plans
Caremaps
Critical Pathways
Computer charting

Methods of Documentation

Traditional (source
oriented client record)
Problem Oriented Medical
Record (POMR)
-SOAP
-PIE
-Focus DAR
Charting by exception

Documentation

NN (nurses notes) best assessment

of pt. care.
Most used section of the medical record in legal cases

Documentation or Charting is a skill

Record of pt.s condition, activities
and events that occurred to the
PATIENT.
Not a diary of your activities.
Includes Subjective & Objective
info

Documentation

Chart facts, not your opinion

Use quotations if pt. said it.
Be specific!! Using nonspecific terms
implies doubt about your knowledge.
i.e. appears/seems/tolerated well etc.
In most cases when care or
observations are not charted it means it
wasnt done
ABCs: Accuracy/Brevity/Completeness

Guidelines for Documentation:

Content

Focus on pt.
Not a novel or essay
Use short sentences
Abbreviations
Symbols
Dont need to use word pt.

Guidelines for Documentation:

Timing

Chart as soon as possible after

care/observations
NEVER chart what you plan to do
Date & time each entry in the margin

Guidelines for Documentation:

Format

Use forms as per agency policy(i.e. flow

sheets, graphic sheet, NCP, progress
notes)
Follow agency guidelines regarding color
ink, approved abbreviations, format of
time (i.e. military/standard)
Write LEGIBLY-questionable info implies
doubt suggests you lack reasonable
knowledge
NEVER skip lines!!
Use correct grammar/spelling

Guidelines for Documentation:

Accountability

Record is permanent
Sign full name and title
No erasures
Do Not write ERROR for a mistake
Single line thru mistake, print
Mistaken Entry or ME (if
acceptable) above or next to
mistake, enter correction, initial &
date per policy

Guidelines for Documentation:

Confidentiality

Students only use patient initials on

assignments
Only caregivers need to know info in
chart
Follow facility policy for pt. review of
chart.

Other Guidelines for

Documentation

Hospitalscomputers

Home carelaptops

Telephone
orders