DOCUMENTATION
- Is the process of preparing a
complete record of client’s care
- It is a vital tool for communication
among healthcare team members
Purposes
- Provide database : provide
healthcare team with database that
become a foundation of care for
client
- Establish communication: establish
a way to communicate to a
multidisciplinary team members
- Provide Chronologic source of
assessment findings : that outlines
the clients source of dta
- Basis for screening or validating
proposed diagnoses
- Source of information : to help
diagnose any problems
- Basis for determining educational
needs : of the clients, families and
significant others
- Basis for determining eligibility for
care and reimbursement
- Permanent legal record : care that
was or not given to the client
- Component of client classification
system
- Access to significant epidemiologic
data : for future investigation,
research and educational endeavor
- Compliance w/ legal, accreditation,
reimbursement and professional
standard requirements
ITEMS THAT NURSES MUST DOCUMENT
Assessment
Nursing diagnosis and patient needs
Intervention /care provided
Patient’s response to care
Patient’s ability to manage continuing care
after discharge
ACCESS TO CHARTS
● Who owns the chart?
Facility
● Patient’s rights
- Patients have the right to the info in
their charts
- They do not have the right to see the
chart on demand or remove anything
from the chart, or remove the chart
from the facility.
● Agency policy
GUIDELINES FOR DOCUMENTATION
- Document legibly and print neatly in non-
erasable ink.
- Use correct grammar and spelling
- Avoid wordiness that creates redundancy
- Use phrases instead of sentences to
record data
- Record data findings, NOT how they were
obtained
- Write entries objectively w/o making
premature judgments or diagnoses.
- Record the client’s understanding and
perception of problems
- Avoid recording the word “normal” for
normal findings
- Record complete information and details
for all client symptoms or experiences
- Include additional assessment content
when applicable
- Support objective data w/ specific
observations obtained during physical
examination
ASSESSMENT FORMS USED FOR
DOCUMENTATION
3 TYPES OF ASS FORMS:
1. Initial assessment forms
- is called a nursing admission or admission
database
- in this form, you can see details of the
patient taken during interview, used upon
patient admission
- the purpose of accomplishing this form is
to establish complete database of the
patient for problem identification, reference
or future comparison
2. Frequent or ongoing assessment
forms
- flow charts help staff to record & retrieve
data for frequent reassessments
- this form is accomplished for on-going
process of assessment, diagnosing,
planning, implementing, and evaluating care
EX. vital signs sheets, assessment flow
chart/progress notes
❏ TPR graphic form: vital signs, temp,
pulse & respirations (also how many
times the patient urinated &
defecated)
❏ Nurses notes: a medical note into a
medical or health record made by a
nurse that can provide an accurate
reflections of nursing assessment,
changes in patient’s condition, care
provided, & relevant info to support
clinical team to deliver excellent care
3. Focused or specialized assessment
forms
- forms that are focused on one major are of
the body for clients who have a particular
problem
- purpose of documenting a particular
problem in this form: is to determine the
status of specific problem identified in
earlier assessment
EX. Cardiovascular or Neurologic
assessment documentation forms/Neuro
vital sign form (NVS form)
❏ NVS form: neurological observation
collect data on the patient’s
neurological status, & can be used in
many reasons including diagnosis as
a baseline observation ff a neurology
surgical procedure & ff trauma
❏ Doctor’s order form: where the
physician writes his/her prescription
or authorizations for the diagnostic
or treatment service to the patient
❏ Kardex: widely used concise method
of organizing and recording data
about the client, it consists of a
series of cards: hept portable index
card or computer generated forms, it
may be a temporary sheet written in
recording frequent changes in the
details of clients care
❏ X-ray/Ultrasound laboratory request
forms: for diagnostic tests, it is filled
out by a nurse during transcription of
a doctor’s order
❏ CBG monitoring sheet: where the
nurse document the sugar level of
patient especially those w/ diabetes
❏ Parenteral fluid sheet: all infusions
such as iv fluid, sidedrips, or blood
transfusion are documented in this
form
❏ Medication sheet: where all the
ordered medications for the patient
are being recorded
❏ Discharged instruction slip: given to
patient upon discharged, where the
instructions of the dr are written
when she/he will be at home for
continuity of care
❏ Do not resuscitate (DNR) form:
given to patients family in the giving
of cardiac or respiratory arrest where
resuscitation is to be done or not
❏ Consent for refusal to undergo any
procedure
DOCUMENTATION IN NDH:
Carrying-out of doctor’s order
When a patient is admitted into the hosp
under a particular service, the resident on
duty for that service is responsible for
examining the patient, and writing
admission orders
The purpose of the physician’s order is to
communicate the medical care that the
patient is to receive while on the hospital as
well as document the tests, medications,
treatments that were ordered
Components of DRs order:
❖ Date
❖ Order
❖ Signature
❖ Time
After writing the order, the dr will endorse
the chart to the nurse & give further
instructions, the nurse will then check the
orders to ensure that all orders will be
transcribed correctly, the nurse can verify
the orders from the dr who made the order,
the nurse will also make sure that the 5
rights are included:
❖ Right name of the drug
❖ Right name of the patient
❖ Right dosage
❖ Right time & frequency
❖ Right route by w/c the drug is to be
administered
The nurse will hand over the chart to the c.i
and endorses the order
The c.i will then check the order and may
verify from the nurse
The c.i will call the assigned student nurse
to carry out the dr’s order
The c.i will read the dr’s order, and give
instructions
The student will be clearly supervised by the
c.i all throughout the process
In carrying out the dr’s order the student
nurse must prepare the ff:
● Kardex - the student nurse will write
significant orders of the dr such as
medications, diagnostic tests,
infusions, and procedures to be
done. This is an up-to-date care that
the patient is receiving
Forms for diagnostic tests, prescriptions and
other request forms if applicable
● Medication ticket: colored card forms
for medication. The color depends
on the time, frequency of the drug
administration
Pink: 3x a day
The medication ticket must contain: Name
of the patient, Room number, name of the
drug, route of administration and frequency
● Medication sheet
DOCUMENTATION DO’S & DON'TS
✔ DO write date & time on all entries
✔ DO use flowsheet/checklist/kardex. Keep info
on flowsheet/checklist current
✔ DO chart as you make observations
DO write your own observations and sign
your own name. Sign and initial every entry
✔ DO describe patient’s behavior and use direct
patient quotes when appropriate
✔ DO record exactly what happens to patient
and care given
✔ DO be factual and complete
✔ DO use only approved abbreviations
✔ DO draw a single line thru an error. Mark
This entry as “error and sign your name”
EX.
✔ DO use next available line to chart
✔ DO document patient’s current status and
response to medical care and treatments
✔ DO write legibly
✔ DO use ink
✔ SO use accepted chart forms
X DON’T begin charting until you check the
name and identifying number on the
patient’s chart on each page
X DON’T chart procedures or cares in
advance
X DON’T clutter notes w/ repetitive or
frequently changing data already charted on
the flowsheet/checklist
X DON’T make or sign an entry for
someone else
X DON’T change any entry because
someone tell you
X DON’T label a patient or show bias
X DON’T try to cover up a mistake or
incident by inaccuracy or omission
X DON’T “white out” or erase an error
X DON’T throw away notes w/ an error on
them
X DON’T use meaningless words and
phrases such as “good day” or “no
complaints”
X DON’T squeeze in a missed entry or
“leave space” for someone else who forgot
to chart
X DON’T write in the margin
SOAPIE DOCUMENTATION
Subjective, Objective, Assessment,
Planning, Intervention, Evaluation
- Is a problem-oriented technique
whereby the nurse identifies and
lists the patient’s health concerns
- It is commonly used in primary
health-care settings
Subjective (subjective data) - chief
complaint or other info the patient/family
members tell you
- Patients complain and concerns on his
own words
EX. “..feeling achy all over my body…”
“...sore throat and chills started last night…”
- Onset, Location, Intensity, Frequency,
Duration and what it makes it better/wors
Objective (objective data) - factual,
measurable data, such as observable signs
and symptoms, vital signs, or test values
- the nurse observes and measure from the
patient or body language
EX. BP, pulse, temperature, weight,
findings, diagnostic test results
Assessment (ass data) - conclusions
based on subjective and objective data and
formulated as patient problems or nursing
diagnoses
- the nurse identifies problems or issues that
need to be addressed
EX. Risk for…
Planning - strategy for relieving the
patient’s problems, including short and long-
term actions
- systematic deliberatively phase of nursing
process that invloves: Decision-Making, and
Problem-Solving
- Planning must be SMART
Interventions - measures you’ve taken, to
achieve expected outcomes
- Direct care treatments: nurse performed in
behalf of client
- Nurse-initiated treatments: resulting from
nursing diagnosis
- Physician-initiated treatments: resulting
from medical diagnosis
Guidelines for interventions
~ Care NOT documented is NOT done
~ Record nursing activities AFTER they are
done
~ Up-to-date, accurate and available
~ Communicated verbally & in writing
Evaluation - analysis of the effectiveness of
your interventions
- it is a planned, on-going purposeful activity
in w/c client and healthcare prof determine
the: Client’s progress & Effectiveness of the
plan
*Conclusions drawn from the evaluation
determines whether nursing activities
should be terminated, continued or changed
*Evaluation continues until the client E - Goal met: Client reported decrease of
achieves the health goals or discharge from pain from 6/10 to 4/10. OR
nursing care Goal met. Patient verbalized, “Medyo
nabawasan na ang sakit ng tahi ko”, with
APPLICATION: pain scale 4/10
Mrs. Cruz who undergone caesarian
Endorsed.
Date (the note was made), Time (you Tan, A./Baquial E.
received/seen the client), General BSN2A NDU
impression of the client at the time you
received her

Date: 6/21/20
Time: 7:00 AM
Medication/Treatments: Ibuprofen 400 mg
Remarks: Received lying on bed w/ D5LR
@ 20 gtts/min @ the level of 250 cc,
hooked @ left metacarpal vein, infusing well

S - “Sumasakit yung tahi ko” as verbalized

by the patient
> Pain scale of 6/10

O - (+) Facial grimace

- Irritabilitity
- Restlessnes

A - Acute pain r/t post CS

P - Within 8 hrs of duty, (client) will report or

verbalize reduce of pain from 6/10 to 4/10

I - Provided quite environment

- Advised to do deep breathing exercise
- Supported the affected area upon
movement
- Administered orally for pain, as ordered
- Followed-up laboratory test results
1-3 = nurse initiated actions
4 = physicians initiated actions (write the
drug on the medication column)
5 = collaborative actions