NCM 108 Health Care Ethics

Vinz Merril G. Reyes, RN, MAN, MSN, ECHA

Assistant Professor IV (Adjunct Faculty)
UPHS Isabela Campus – College of Allied Health Sciences
 Accurate documentation of
actions and outcomes of
delivered care is the hallmark of
nursing accountability.
PROFESSIONAL PRINCIPLES
OF DOCUMENTATION

Documentation is a nursing action that produces a written

and/or electronic account of pertinent client data, nursing
clinical decisions and interventions, and the client’s responses
in a health record (Perry, Potter, Stockert & Hall, 2017).
PROFESSIONAL PRINCIPLES
OF DOCUMENTATION
Nursing documentation is a
vital component of safe,
ethical and effective nursing
practice, regardless of the
context of practice or
whether the documentation
is paper-based or electronic
(CRNNS & CLPNNS, 2017).
PROFESSIONAL PRINCIPLES
OF DOCUMENTATION
Nursing documentation
describes nurses’
accountability and the
expectations for
documentation in all
practice settings, regardless
of the documentation
method or storage (CRNNS &
CLPNNS, 2017).
PROFESSIONAL PRINCIPLES
OF DOCUMENTATION
PROFESSIONAL PRINCIPLES
OF DOCUMENTATION

It must provide a clear and accurate picture of the

patient while under the care of the health care team
(Campos, 2009).
LEGAL BASES OF NURSING
DOCUMENTATION
RA 9173 Article VI
Section 28

Provided, further, that in the

practice of nursing in all
settings, the nurse is duty-bound
to observe the Code of Ethics
for nurses and uphold the
standards of safe nursing
practice.
LEGAL BASES OF NURSING
DOCUMENTATION

BON Resolution No. 220 s.

2004 Article III Section 6

Ethical principle no. 3:

Accurate documentation of
actions and outcomes of
delivered care is the hallmark
of nursing accountability.
LEGAL BASES OF NURSING
DOCUMENTATION
2012 National Nursing Core Competency Standards

• Practices in accordance with legal principles and the code

of ethics in making personal and professional judgment
1
• Utilizes the nursing process in the interdisciplinary care of
clients that empowers the clients and promotes safe
2 quality care

• Maintains complete and up to date recording and reporting

system
3
LEGAL BASES OF NURSING
DOCUMENTATION
RA 10173 Data Privacy Act of 2012
1. All personal information must be collected for reasons that are
specified, legitimate, and reasonable. In other words, customers must
opt in for their data to be used for specific reasons that are
transparent and legal.
2. Personal information must be handled properly. Information must be
kept accurate and relevant, used only for the stated purposes, and
retained only for as long as reasonably needed. Customers must be
active in ensuring that other, unauthorized parties do not have
access to their customers’ information.
3. Personal information must be discarded in a way that does not make
it visible and accessible to unauthorized third parties.
ESSENTIAL CHARACTERISTICS
OF NURSING DOCUMENTATION
Factual,
Accurate &
objective &
relevant
client-centered

Organized,
Complete logical &
sequential

Compliant with
professional
standards
PURPOSES OF NURSING
DOCUMENTATION
Communication among the health care team

Continuity of care

Professional accountability

Legal document

Quality assurance

Funding & resource management

Research
ISSUES IN NURSING
DOCUMENTATION
Co-Signing & Countersigning
Entries
 Co-signing implies shared accountability;
therefore, the person co-signing needs to
witness or participate in the event (SRNA,
2011).
 Countersigning does not imply that the
second person provided the service but it
does not imply that the person approved or
verified that the service or record was
completed.
ISSUES IN NURSING
DOCUMENTATION
Verbal & Telephone Orders

 Verbal orders should only be accepted in

emergent or urgent situations where the
prescriber cannot document their orders.
 Telephone orders should be limited to
situations when the prescriber is not present.
 The prescriber may be accountable to
review and co-sign their verbal and
telephone orders as soon as reasonably
possible or within the time frame allowable.
ISSUES IN NURSING
DOCUMENTATION
Text & E-Mail Orders
 This type of communication is discouraged
due to the risk of violation of confidential
health information and incomplete
communication of client status.
 Text or e-mail should not be used for provider
convenience; however, if the text or e-mail
communication is the only way health
professionals can communicate in the best
interest of the client, hospital policy must be
available to support this.
ISSUES IN NURSING
DOCUMENTATION
Date, Time, Signature, Designation

 Signatures and initials need to be

identifiable.
 Personal initials can only be used if a
master list matching the health care
professional’s initials with a signature and
designation.
ISSUES IN NURSING
DOCUMENTATION
Objectivity and Subjectivity

 Documentation should include

objective statements related to the
nursing process.
 Subjective information should provide
accurate examples of what was said
using quotes appropriately along with
identification of the individual who made
the statement.
ISSUES IN NURSING
DOCUMENTATION
Generalizations

 Avoid generalizations and vague

phrases or expressions.
 Such vague statements are conclusions
without supported facts.
ISSUES IN NURSING
DOCUMENTATION
Bias and Labels

Only document conclusions that can be

supported by data and avoid value
judgments or unfounded conclusions.
 Select neutral terminology or describe
observed behaviors.
ISSUES IN NURSING
DOCUMENTATION
Legibility & Spelling

 Correct spelling and legibility of nursing

documentation demonstrates attention to
detail and nursing competence.
 Misspelled words or illegible entries can
result in misinterpretation of information
and could result in client harm.
ISSUES IN NURSING
DOCUMENTATION
Blank (White) Space

 Blank or white space in paper-based

documents should be avoided as this
presents an opportunity for others to add
information unknown to the original
author.
ISSUES IN NURSING
DOCUMENTATION
Abbreviation, Symbols & Acronyms

 The use of abbreviations, symbols, or

acronyms can be efficient form of
documentation if their meaning is well
understood.
 Abbreviations and symbols that are
obscure, obsolete, poorly defined or have
multiple meanings can lead to errors.
ISSUES IN NURSING
DOCUMENTATION
Errors & Changes

 If an error occurs, do not make entries

between lines, do not remove anything,
and do not erase or use correction
products, stickers or felt pens to hide or
obliterate an error.
 Failing to correct an error appropriately
or correcting or modifying another’s
documentation may be interpreted as
falsification of a record.
TYPES OF NURSING
PROGRESS NOTES

Narrative
SOAPIE
Notes

Focus
PIE
Charting
FOCUS CHARTING

Focus charting brings the focus of care to

the patient and the patient’s concerns.
FOCUS CHARTING

The principal advantage of focus charting is

in the holistic emphasis of the patient and
his/her priorities including ease in charting.
FOCUS CHARTING
• To describe a patient’s
FOCUS problem/concern from the care
plan

•Subjective or objective information supporting

DATA the stated focus or describing the observation
at the time of the significant event

• Describes the nursing

ACTION interventions

•Describes the patient’s response to the

RESPONSE intervention
•Describes how the care plan goals have been
attained
NURSING DOCUMENTATION
ERRORS
CONCLUSION
Nurses should recognize that the
documentation of their nursing
decisions and actions is equally as
valuable, professionally and
legally, as the direct care provided
to clients. Quality documentation is
an important element of nursing
practice, essential to positive client
outcomes and a key component
of meeting their standards of
practice.
 THANK YOU!

Vinz Merril Reyes @vinzeeelog

@vinzeeelog Vinz Merril Reyes