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State-of-the art

Foreign Author

According to Roussel (2006) recommends that documentation should be

done after rendering care to the patient. It should be updated minute by minute

after an emergency. Any contradictions, inconsistencies and unexplained time

gaps can be a potential problem during litigation that is why accuracy is after

being practiced.

As reckoned by Potter (2002) Documentation is defined as anything

written or printed that is relied on as a record of proof for authorized persons.

Effective Documentation reflects the quality care and provides evidence of each

health care team member’s accountability in giving care. The record serves as a

description of exactly what happened to a client. Nursing care may have been

excellent however; “care not done is care not done” in a court of law.
Navuluri (2007) emphasized that complete documentation will be very

beneficial to the patient especially in improving the quality care provided. Caring

for patient; dealing with special situation; and practicing self legally; each entry

tells exactly what to consider and document, so the nurses can ensure quality

patient care, continuity of care, and legal protection like provides practical advice

that is useful for everyday documentation challenges, explains how to document

unusual or difficult developments or events, includes tips and advice to help

streamline documentation without sacrificing accuracy, provides explanations of

legal terms in easy to understand language, shows and explains how to

document safely and correctly to ensure quality and continuity of care. Also uses

case histories to illustrate key legal –points and to explain how and why to

document in a variety of documentation system.

As stated by Bedoian (2006) Documentation systematically organizes

nursing activities to ensue the highest quality of care. Allows the nurse to

determine which problems can be alleviated and which potential problems can be

prevented. Documentation allows you to communicate with other members of the

health care team. Meaning, nurses and other health care provider has

documentation as their way of communication. It keeps tracks of the patient’s

current condition and progress and it is used as a measure to the continuity of

care. It also serves as a reference or healthcare provider’s guidelines for further

Local Author

According to Venzon (2006), documentation can be used as a legal proof

or record for authorization. It can stand as evidence to the nurse’s accountability

in giving such care. It should be accurate and concise with the patient’s needs,

problems, capabilities and limitations.

As stated by Nolledo (1999) documentation accurately and completely

nursing care rendered reflects : what,who,when,where,why and how of nursing

care. Nursing Audits (documentation) reveals accurate, complete and updated

data according to criteria.

According to the board of resolution of board of nursing , documentation

must be complete and concise , speed is essential but making it slowly and

surely is the best way to avoid errors.

As cited by Raymond (2002), The nursing files, no matter how they are

created and reserved, they have the ability to be modified due to new data, and

that renders nursing documentation as a dynamic process.

As said by Accelo (2007), Revolutionary approach to long term clinical

documentation means all the common condition encountered in long term care at

your fingertips. Also benefit from assessment and documentation guidelines by

system to help identify problems, enteral and parenteral nutrition and

observations and relevant documentation.

Nagtalon (2006) stated that nursing documentation shall address the

patient’s needs, problems, capabilities and limitations, because this is done to

determine the quality of care that the nurse had provided to the patient, it is used

to measure if the standard are being met. Documentation serves as a legal

evidence of care and a description of what happened to the patient.

Foreign Thesis

As cited by Cheevakasemsook et al (2006), documentation verified

continuity of care. It acts as legal evidence during the nursing process and it

enhances the quality of patient care. Though it has complexities the nurse must

overcome it for him/her to be able to make a good nursing documentation. The

nurse should be competent and must be motivated in any given aspect if

possible. Documentation has always its complexities but it only requires a good,

confident and assertive nurse.

Acoording to Boldreghini (2000) deductively, nursing documentation is an

extremely essential process of nursing practice and an integral piece of each

nursing intervention. Its contribution to the course of the patient’s health is

undeniable for the reason that it organizes his care, and facilitates the

communication among the members of the therapy group. The nursing files, no
matter how they are created and reserved, they have the ability to be modified

dew to new data, and that renders nursing documentation a dynamic process.

Bjorvell (2002) Stated that structured documentation improves the skills as

registered nurses but isn’t sufficient, it must be used in combination with other

complex methods.

Lamond L,(2002) held that The report of the shift change is the report that

is given to all the nurses of the next shift. Its purpose is to provide constant care

to the patients, giving to the employees of the new shift a brief summary of the

needs of the patients and instructions for their care. The reports during the shift

change can be given written or orally, either by personal communication between

the nurses or by a recording cassette. The report person by person allows the

listener to make questions during the report. The written and recorded reports

are usually shorter and less time is wasted.

According to Autin (1995),The educational preparation that long term care

is thought to influence administrator to influence their professional socialization.

This process influences the perceptions of long term care (LTC) administrators,

which then influences their actions. The question does the advanced education

preparation of currently licensed LTC administrators significantly affect their

perceptions of what important competencies for future LTC administrators makes

the results indicated that there are no significant difference in the mean scores
between those administrators with higher degrees and those with less than

degree. Knowledge of trend in health care and quality assurance was second

and the third most important competencies indicated needed by both groups. No

significant correlations were found between category scores of perceived

importance and number of years as a licensed long term care administrator.

As cited from Nursing Document research system of nursing care (2001)

Documentation is the written and legal recordings of the interventions that

concern the patient and it includes a sequence of process

Local Thesis

The College of registered Nurses in British Columbia, as cited by Sablad

(2008), Stated that documentation is concerned with the status of the patient.The

implementation done by the nurse and the response of the patient.

Documentation also promoted better care from the nurse to the patient.It

supports the rights of the patient and meets the legal standards of the nurse.

Documentation when if comes to a patient medical record is a vital aspect of

nursing practice: It must be accurate, appropriate, comprehensive, and flexible

enough to retrieve clinical data, maintain continuity of care and reflects current

standards of nursing practice. The primary purpose of documentation is

fundamental communication with the other health care teams and it serves as the
patients perspective on his/her health and well being, the care provided and the

effect of care and for continuity of care.

As cited by Catalano (2001) Documentation is the written and legal

recording of the interventions that concern the patient and it includes a sequence

of processes. Documentation is established with the personal record of the

patient, which constitutes a base of information on the situation of his health. The

importance of nursing documentation is neuralgic, provided that without it, there

cannot be a complete qualitative nursing intervention and not even an effective

care for the patient. In the purposes of nursing documentation are included the

research on a more effective care of the already detected problems, the

programming of care. The patient’s file should describe his current situation and

reflect the entire nursing process. Regardless of the documentation system that

is used by an institution, nurses register constantly various evidence of the

nursing activity, throughout the duration of the care benefit.

Diamante et al(2005) aimed to determine the relationship between the

demographic profile and the level of hindrances in doing SOAPIE charting in

seniors, finding out that there is a significant between hindrances and their

Foreign author

Roussel,Linda. Nursing management & Leadership; C&E publishing Inc. 2004

Potter, Patricia, Fundamentals of Nursing 5th Edition; Mosby, 2002

Navuluri,r. Documentation: what,why,when,where,who and how? 1992

Bedoian,J, Documentation in action; Lipincott Williams and wilkins , 2006

Local author

Prof. Jose N. Nolledo,Revised regulations on Standards of safe nursing

practice;,LL.B, LL.M; Phil graphic arts Inc. 1999

Venzon & Nolledo. Nursing management towards quality care. C& E publishing
Inc. 2006

PRC board of nursing, board resolution #220 article 3 sec 6 2004

Raymond L. Documenting for PROs. Nursing 2002;

Nagtalon;J,Nursing management towards quality care 3rd edition. Quezon city

phil. C&E publishing Inc, 2006

Barbara Acello, clinical documentation: an essential guide for long-term care


Foreign thesis

Cheevakasemsook,Aree. The Study of Nursing documentation complex.2006

Boldreghini S, Elder – Sorrells K,Turner ZM, Wender RG, Hart JM, et al.
Evaluation of documentation, before and after implementation of a nursing
information system in an acute care hospital. 2000

Bjorvell C., comprehensive doc intl university of Stockhold, Sweden 2002

Lamond D. The information content of the nurse change of shift report: A

comparative study. Journal of Advanced Nursing 2000

Autin,F. a study of perceptions of long term care administrators regarding the

importance of Needed competencies 1995
Document research system of nursing care, http://www.nursing
.gr/documentation®.pdf (2001)

Local thesis

Sablad,Jeremiah.Content Preparedness for SOAPIE documentation of Level III-

Clinical instructors of the UPHSL, Biñan,Laguna.2008

Catalano K, Critical path network: Improve patient safety to comply with new
standards: Demonstrate evidence to JCHAO surveyors. Hospital Case
Management. 2001

Diamante,D, Relationship between the demographic profile and the level of

hindrances in doing SOAPIE charting of Senior students, University of Perpetual
Help System,Biňan,Laguna. 2005