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MODULE7
Intervention, Evaluation and
Documentation

The nursing process is a systematic, rational method of planning and providing

individualized nursing care. Its purpose is to identify a client’s health status and actual or
potential health care problems or needs, to establish plans to meet the identified needs, and
to deliver specific nursing interventions to meet those needs. The client may be an individual,
a family, a community, or a group. In the phase of implementing carrying out (or delegating)
and documenting the planned nursing interventions. The purpose of implementing is to assist
the client to meet desired goals/outcomes; promote wellness; prevent illness and disease;
restore health; and facilitate coping with altered functioning. The activities involved in
implementing are; reassess the client to update the database, determine the nurse’s need for
assistance, perform planned nursing interventions, communicate what nursing actions were
implemented, document care and client responses to care, and give verbal reports as
necessary. While in the evaluating, measuring the degree to which goals/ outcomes have
been achieved and identifying factors that positively or negatively influence goal achievement.
The purpose of evaluating is to determine whether to continue, modify, or terminate the plan
of care. The activities involved in evaluating are; collaborate with client and collect data
related to desired outcomes, judge whether goals/ outcomes have been achieved, relate
nursing actions to client goals/ outcomes, make decisions about problem status, review and
modify the care plan as indicated or terminate nursing care, document achievement of

outcomes and modification of the care plan. Topic 1. NURSING

INTERVENTION
The first three nursing process phases—assessing, diagnosing, and planning—
provide the basis for the nursing actions performed during the implementing step.
Implementing is the action phase in which the nurse performs or delegating and documenting
the planned nursing interventions that were developed in the planning step and then
concludes the implementing step by recording nursing activities and resulting to client
responses. The nurse performs nursing interventions to resolve or reduce the identified
nursing problem on the patient, with the patient, and for the patient. It implies that the patient
is not a passive recipient of care but must always be regarded as an active participant in his
care.
The purpose of nursing implementation is to assist the client to meet the desired
goals/outcomes; promote wellness; prevent illness and disease; restore health; and facilitate
coping with altered functioning. The nurse involves in giving nursing care / carrying out the
planned nursing activities, delegating the care to another health care team member,
continuing data collection, documenting and validating care.
I. Nursing Interventions Classification (NIC)
 Is consists of doing and documenting specific nursing actions.
 The implementing phase provides the actual nursing activities and client responses that
are examined in the final phase, the evaluating phase.
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 Using data acquired during assessment, the nurse can individualize the care given in the
implementing phase, tailoring the interventions to fit a specific client rather than applying
them routinely to categories of clients (e.g., all clients with pneumonia).
 While implementing nursing care, the nurse continues to reassess the client at every
contact, gathering data about the client’s responses to the nursing activities and about
any new problems that may develop.

A nursing activity on the client’s care plan for the NIC intervention Airway
Management might read “Auscultate breath sounds q4h.” When performing this activity, the
nurse is both carrying out the intervention (implementing) and performing an assessment.
Some routine nursing activities are, themselves, assessments.

For example, while bathing an older client, the nurse observes a reddened area on
the client’s sacrum. Or, when emptying a urinary catheter bag, the nurse measures 200 ml of
offensive smelling, brown urine.

II. Types of Nursing Interventions

Nursing action Example

1. Independent/ - Initiate carrying out nurses actions After identifying the patient’s problem of
Nurse-initiated without the supervision of doctor and a distended bladder, the nurse positions
interventions result from their assessment of the patient to semi- fowler’s, places him
patient needs. on the bedpan, then applies slight
pressure over his hypogastric area.
- Those activities that nurses are
initiate on the basis of their
knowledge and skills include:
physical care, assessment,
emotional support and comfort,
teaching, counseling, making
referrals to other health care
professionals, and environmental
management.
2. Dependent/ - Nurses carrying out physician Physician prescribed patient Intravenous
Physicianinitiated prescribed orders, which commonly fluid and antibiotics medication thru IV.
interventions direct the nurse to provide The nurse initiate carrying out those
medications, IV therapy, diagnostic order given by the doctor.
tests, treatments, diets, and activity.
3. Interdependent - Actions that the nurse carries out in The physician might order PT to teach
/Collaborative collaboration with other health care client crutch-walking. The nurse would
interventions professionals. be responsible for informing the PT
department and for coordinating the
client’s care to include the PT sessions.
When the client returns to the
ward/room, the nurse would assist with
crutch-walking and collaborate with the
physical therapist to evaluate the client’s
progress.
Nursing Interventions
 Is an activities the nurse plans and implement to help a patient achieve identified goals.
 any treatment based on clinical judgment and knowledge that the nurse performs to enhance
patient outcomes.

When planning nursing interventions, the nurse should identify:

 What is to be done?
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 When the activity is to be done?
 Duration for each intervention.
 Any follow up activity.
 Date interventions were selected.
 Sequence in which nursing activities are to be performed.  Signature of the nurse writing
the plan of care.

Rationale of Nursing Interventions – based on principles and theories from various

discipline (anatomy and physiology, psychology, sociology,etc.)
 not necessary to be written in an NCP, but for student nurses, this is a sort of practice
and it is important to know the rationale because nursing process is incomplete and
potentially unsafe unless nurses base the choices of nursing action on appropriate
rationale.
III. Components of Nursing Intervention a. PDx (Diagnostics) ex: weighing,
VS, Hgt monitoring, measuring abdominal circumference.

b. PTx (Therapeutic) ex: Administering of Paracetamol 500 mg. 1 tab.

q4H as ordered by the physician, enforce fluid intake.

c. PEd ( Education or Health teaching) ex: Instruct the patient on

proper wound dressing.

IV. Criteria for Selecting Nursing Interventions

1. safe and appropriate for the patient (considering his health, age, condition)
2. congruent with other therapies
3. develop the behavior described in the goal statement
4. realistic
• Necessary to assess and monitor effect of medical treatment which are included in the
therapeutic regimen.
• Some medical orders may require nursing activities such as assessment prior to
carrying out doctor’s order.

Example:
Medical order: Lanoxin 0.125 mq QID.
Nursing actions:
1. Count apical pulse prior to giving medication.
2. Give lanoxin 0.125 mg QID if pulse is above 60 beats/min. Hold if lesser than 60
bpm.
3. Notify physician if drug is withheld.

Writing Individualized Nursing Interventions

 The nurse writes the chosen/ planned nursing interventions on the care plan.
 Nursing interventions on the care plan should be dated when they are written and reviewed
regularly at intervals that depend on the individual’s needs.

Example:
Nursing Diagnosis Short term Goal Interventions
Impaired urinary The patient will - Record intake and output for 24 hours.
elimination r/t previous void at least once - Apply alternate hot and cold compress for 15
indwelling 6 hours after the minutes on hypogastric area every 2 hours.
catheterization. removal of - Offer assistance to the bathroom every 2 hours.
catheter. - Provide privacy for voiding attempts.
- Encourage fluid intake of at least 1 glass of water

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every hour.
- Encourage voiding attempt in sitz bath, tub bath or
shower to enable to void in 6 hour.
V. Implementing Skills - nurses need cognitive, interpersonal, and technical skills.
1. Cognitive skills - problem solving, decision making, critical thinking, and creativity.
2. Interpersonal skills - verbal and nonverbal, interacting directly with one another.
 The effectiveness of a nursing action often depends largely on the nurse’s ability to
communicate with others. The nurse uses therapeutic communication to understand
the client and in turn be understood.
3. Interpersonal skills - are necessary for all nursing activities: caring, comforting, referring,
advocating, counseling, supporting, conveying knowledge, attitudes, feelings, interest, and
appreciation of the client’s cultural values and lifestyle.
4. Technical skills - such as manipulating equipment, giving injections, bandaging, moving,
lifting, and positioning clients. These skills are also called tasks, procedures, or psycho
motor skills. Psycho motor refers to physical actions that are controlled by the mind, not by
reflexes.

Example:
When the nurse inserting a urinary catheter - the nurse needs cognitive knowledge of
the principles and steps of the procedure, interpersonal skills to inform and reassure the
client, and technical skill in draping the client and manipulating the equipment.

VI. The Process of Implementing - normally includes the following:

The Five Activities of the Implementing Phase.

1. Reassessing the client
 The nurse reassess client to make sure the intervention is still needed. Even though
an order is written on the care plan, the client’s condition may have changed.

For example, a client has a nursing diagnosis of Disturbed Sleep Pattern related to
anxiety and unfamiliar surroundings. During rounds, the nurse discovers that she is
sleeping and therefore defers the back massage that had been planned as a
relaxation strategy.

2. Determining the nurse’s need for assistance - such as following reasons:  unable to
implement the nursing activity safely or efficiently alone (e.g., ambulating an unsteady
obese client).
 Assistance would reduce stress on the client
(e.g., turning a person who experiences acute pain when moved).
 Lacks of knowledge or skills to implement a particular nursing activity.
 Not familiar with a particular equipment needs assistance the first time it is applied.
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3. Implementing the nursing interventions
 Explain to the client what interventions will be done, what the client is expected to do,
and what the expected outcome is. For many nursing activities it is also important to
ensure the client’s privacy,
4. Supervising the delegated care
 If care has been delegated to other health care personnel, the nurse
responsible for the client’s overall care must ensure that the activities have
been implemented according to the care plan.
 Other health care personnel may be required to communicate their activities to
the nurse by documenting them on the client record, reporting verbally, or
filling out a written form.
5. Documenting nursing activities
 After carrying out the nursing activities, the nurse completes the implementing
phase by recording the interventions and client responses in the nursing
progress notes.
 The nurse may record routine or recurring activities in the client record at the end of a
shift. Record of nursing intervention must be up to date, accurate, and available to
other nurses and health care professionals.
 Immediate recording after nursing intervention was implemented helps safeguard the
client. Nurses also report client status at a change of shift and on a client’s discharge
to another unit or health agency in person, via a voice recording, or in writing.
Remember: Nursing care must not be recorded in advance because the nurse may
determine on reassessment of the client that the intervention should not or cannot be
implemented.
For example, a nurse is authorized to inject 10 mg of morphine sulfate
subcutaneously to a client, but the nurse finds that the client’s respiratory rate is 8
breaths per minute. This finding contraindicates the administration of morphine (a
respiratory depressant). The nurse withholds the morphine and reports the client’s
respiratory rate to the attending physician.
VII. The Guidelines for Nursing Intervention
a) The interventions must be based on scientific knowledge, nursing research, and
professional standards of care.
 The nurse must be aware of the scientific rationale, as well as possible side effects or
complications, of all interventions.
For example, a client has been taking an oral medication after meals; however, this
medication is not absorbed well in the presence of food. Therefore, the nurse will
need to explain why this practice needs to be altered.

b) Clearly understand the interventions to be implemented.

 The nurse must be knowledgeable on each intervention, its purpose in the client’s
plan of care, any contraindications, and changes in the client’s condition that may
affect the physician’s order.

c) Adapt activities to the individual client.

 A client’s beliefs, values, age, health status, and environment are factors that can
affect the success of a nursing action.
For example, the nurse determines that a client chokes when swallowing pills, so
consults with the primary care provider to change the order to a liquid form of the
medication.

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d) Implement safe care.
For example, when changing a sterile dressing, the nurse practices sterile technique
to prevent infection.
For example, when giving a medication, the nurse administers the correct
dosage by the ordered route.

e) Provide teaching, support, and comfort.

 The nurse should always explain the purpose of interventions, what the client will
experience, and how the client can participate. The client must have sufficient
knowledge to agree to the plan of care and to be able to assume responsibility for as
much self-care as desirable.

f) Be holistic.
 The nurse must always view the client as a whole and consider the client’s responses
in that context.
For example, the nurse honors the client’s expressed preference that interventions
be planned for times that fit with the client’s usual schedule.

g) Respect the dignity of the client and enhance the client’s self-esteem.
 Providing privacy and encouraging clients to make their own decisions are ways of
respecting dignity and enhancing self-esteem.

h) Encourage clients to participate actively in implementing the nursing interventions.

 Active participation enhances the client’s sense of independence and control.
 The amount of desired involvement may be related to the severity of the illness;
client’s culture, fear, understanding of the illness, and understanding of the
intervention.

VIII. Principles in Implementation of Nursing Care:

a.) Maintaining the individuality of man.
• implies that emphasis of nursing care is the person who receives such care, not the
procedure or activity to be carried out.
b.) Consideration for the patient’s safety, comfort & privacy.
• respect for patient’s feelings and modesty.
c.) Considering economy of time, effort & materials.
• applies not only to the nurse but also to the patient.
d.) Neatness of the finished product.
• aesthetic aspects of care giving.

IX. Aspects of the Nurse’s Role in Implementation of Care:

1. Care aspect - focuses on promoting, maintaining, and The care aspects of the
restoring the patient’s physical or psycho nurse’s role measure designed
social well-being. primarily to promote comfort.
2. Curative - activities which fall under the nurse’s
dependent functions. Example: TSB is curative
3. Protective - measures to reduce environmental hazards. because it puts the patient in
the best condition for recovery:
4. Teaching - all activities the nurse engages in to teach
protective because it removes
health maintenance and promotion,
skin waste; and instructional
prevention of illness, and rehabilitation to
because the nurse explains
individuals and families.
why the patient has to keep his
5. Patient - when the nurse speaks in
skin clean.
advocate behalf of the patient.
Topic 2. EVALUATION - is the fifth/ final phase of the nursing process.

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On this phase, the nurse determine the client’s progress toward achievement of
goals/outcomes and the effectiveness of the nursing care plan. It also identifying factors that
positively and negatively influence goal achievements The nurse demonstrate responsibility
and accountability for their actions, indicate interest in the results of the nursing activities.
Immediately evaluating nursing intervention enables the nurse to correct any deficiencies and
modify the care plan as needed. Whether the nursing interventions should be terminated,
continued, or changed. The nurse uses clinical judgments about goal achievement to
determine whether the care plan was effective in resolving, reducing, or preventing client
problems.

Relationship of Evaluating to Other Phases of Nursing Process

Successful evaluation depends on the effectiveness of the steps that precede it.
 Assessment data must be accurate and complete so that the nurse can formulate
appropriate nursing diagnoses and desired outcomes.
 The desired outcomes must be stated concretely in behavioral terms if they are
to be useful for evaluating client responses.
 Without the implementing phase in which the plan is put into action, there would
be nothing to evaluate.

The Evaluation Phase has five Components :

1) Collecting data related to desired outcomes
2) Comparing data with desired outcomes
3) Relating nursing activities to outcomes
4) Drawing conclusions about problem status
5) Continuing, modifying, or terminating the nursing care plan

When determining whether a goal has been achieved, the nurse can draw one of
three possible conclusions:
1. The goal was met; that is, the client response is the same as the desired outcome.
2. The goal was partially met; that is, either a short-term outcome was achieved but
the long-term goal was not, or the desired goal was incompletely attained.
3. The goal was not met; after determining whether or not a goal has been met, the
nurse writes an evaluation statement (either on the care plan or in the nurse’s notes).

An Evaluation Statement consists of two parts:

1. Conclusion - is a statement that the goal/desired outcome was met, partially met,
or not met.
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2. Supporting data - are the list of client responses that support the conclusion.

For example: Goal met: Oral intake 300 ml more than output; skin turgor resilient;
mucous membranes moist.

Example of Evaluation:
Goal statement: Will ambulate half the length of hallway w/ assistance 3x daily.

Evaluative Statement:
Goal partially met: Patient refused to ambulate in the morning but walked
to the bathroom once in the afternoon w/ the
assistance of one nurse .

conclusion supporting data

(1) Goal statement: Body temperature will decrease from 38.50C to 37.50C within 2 hours
after administering TSB.
Evaluative statement: Goal met. Body temperature went down to 37.2 0C within 2 hours
after TSB administration.

(2) Goal statement: verbalization of decreased pain from a scale of 2 to 1 (where

3=severe, 2=moderate, 1=mild, 0=no pain) within the shift.
Evaluative statement: Goal not met. Patient verbalized that the pain intensity remained the
same .

Evaluation of goals, selected outcomes, and interventions needs to be continuous,

with ongoing assessment and reassessment of the situation. Priority needs can change
quickly and must be re-prioritized when problems occur. Infants and young children are
vulnerable to rapid change in their condition due to their small body size, disproportionate
size of organs, and immaturity of body systems. Also, they may not be able to verbalize how
they are feeling. Older adults may have conditions that impair communication, such as
aphasia from a cerebrovascular accident, dementia, multiple sclerosis, or other neurologic
conditions. In such cases, the nurse needs to be even more smart in performing nonverbal
assessments, being alert to potential problems, and detecting changes in the client’s
condition. If evaluations are done often and thoroughly, changes can be made quickly to
intervene more effectively and improve outcomes. Constant assessment, communication,
and interpersonal skills are as essential in the evaluation phase as they are during the initial
assessment.

Topic 3 . DOCUMENTATION

Effective communication among health professionals is vital to the quality of client

care. Generally, health personnel communicate through discussion, reports, and records. 1)
Discussion - is an informal oral consideration of a subject by two or more health care
personnel to identify a problem or establish strategies to resolve a problem.

2) Report - is oral, written, or computer-based communication intended to convey

information to others. For instance, nurses always report on clients at the end of a hospital
work shift. A record, also called a chart or client record, is a formal, legal document that
provides evidence of a client’s care and can be written or computer based.

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3) Client Record - is called recording, charting, or documenting. Although health care
organizations use different systems and forms for documentation, all client records have
similar information.

 The Joint Commission requires client record documentation to be;

a) Timely
b) Complete
c) Accurate
d) Confidential
e) Specific to the client.

 The American Nurses Association Code of Ethics (2001) - states that “ the nurse has a
duty to maintain confidentiality of all patient information”.
 The client’s record is also protected legally as a private record of the client’s care.
 Access to the record is restricted to health professionals involved in giving care to the client.
 The Health Insurance Portability and Accountability Act of 1996 - maintain the privacy
and confidentiality of protected health information.

The following are some suggestions for ensuring the confidentiality and security of
computerized records:
1. A personal password is required to enter and sign off computer files. Do not share this
password with anyone, including other health team members.
2. After logging on, never leave a computer terminal unattended.
3. Do not leave client information displayed on the monitor where others may see it.
4. Shred all unneeded computer-generated worksheets.
5. Know the facility’s policy and procedure for correcting an entry error.
6. Follow agency procedures for documenting sensitive material.
7. Information technology (IT) personnel must install a firewall to protect the server from
unauthorized access.

The Purposes of Client Records

1. Communication
2. Planning client care
3. Auditing health agencies
4. Research
5. Education
6. Reimbursement
7. Legal documentation
8. Health care analysis

Documentation Systems
1. Source-oriented record - traditional paper form and traditional client record.
 Narrative charting - is an example of source oriented record. It consists of written
notes that include routine care, normal findings, and client problems. Arrange
chronological order is frequently used.
 Narrative recording - is being replaced by other systems, such as charting by
exception and focus charting.

For example, an agency using a charting-by exception system may use narrative charting when
describing abnormal findings.
 The disadvantage is that information about a particular client problem is scattered
throughout the chart, so it is difficult to find chronological information on a client’s
problems and progress. This can lead to decreased communication among the health
team, an incomplete picture of the client’s care, and a lack of coordination of care.

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A narrative note in an EMR.

(Neehr Perfect® networked educational EHR featuring World VistA. Courtesy of Archetype Innovations, LLC 2010).
Type of Record 8) Medical history
1) Admission sheet 9) Physical examination
2) Initial nursing assessment 10)Physician’s order form
3) Graphic record 11)Physician’s progress notes
4) Daily care record 12)Consultation records
5) Special flow sheet 13)Physical therapist’s record 14)
6) Medical record Social service record.
7) Nurses’ notes 15) Client’s discharge plan and referral
summary

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Components of the Source-Oriented Record

2. Problem-Oriented Medical Record (POMR) or Problem-Oriented Record (POR)

 established by Lawrence Weed in the 1960s, the data are arranged according to the
problems the client has rather than the source of the information.
 Plans for each active or potential problem are drawn up, and progress notes are recorded
for each problem.
 The advantage of POMR is that it encourages collaboration and the problem list placed in
the front of the chart. The health care provider will became aware to the client’s needs and
makes it easier to track the status of each problem.
 The disadvantages of POMR are that (a) caregivers differ in their ability to use the
required charting format, (b) it takes constant vigilance to maintain an up-to-date problem
list, and (c) it is somewhat inefficient because assessments and interventions that apply to
more than one problem must be repeated.

The Basic Components of Problem - Oriented Medical Record

a) Database - all information about the client (nursing assessment, history, social and family data,
result of physical examination, baseline diagnostic tests). The data are constantly updated as
the client’s health status changes.

b) Problem list - it is usually kept at the front of the chart and serves as an index to the numbered
entries in the progress notes. It is continually updated as new problems are identified and
others resolved. The problem list which includes; the client’s physiological, psychological,
social, cultural, spiritual, developmental, and environmental needs.

c) Plan of care - must be based on client’s needs.

d) Progress notes - are numbered to correspond to the problems on the problem list and may be
lettered for the type of data.
For example, the SOAP format is frequently used. SOAP is an acronym for subjective data,
objective data, assessment, and planning.

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S—Subjective data consist of information obtained from what the client says. It describes
the client’s perceptions of and experience with the problem.
O—Objective data consist of information that is measured or observed by use of the
senses (e.g., vital signs, laboratory and x-ray results).
A—Assessment is the interpretation or conclusions drawn about the subjective and
objective data. During the initial assessment, the problem list is created from the
database, so the “A” entry should be a statement of the problem.
P— Plan of care designed to resolve the stated problem. The initial plan is written by the
person who enters the problem into the record.
 All subsequent plans, including revisions, are entered into the progress notes.
 The SOAP format has been modified. The acronyms SOAPIE and SOAPIER refer to formats
that add interventions, evaluation, and revision.
I—Interventions refer to the specific interventions that have actually been performed by
the caregiver.
E—Evaluation refers to the client responses to nursing interventions and medical
treatments. This is primarily reassessment data.
R—Revision reflects care plan modifications suggested by the evaluation. Changes may
be made in desired outcomes, interventions, or target dates. Newer versions of
this format eliminate the subjective and objective data and start with assessment,
which combines the subjective and objective data. The acronym then becomes
AP, APIE, or APIER.

An example of a problem list in the POMR in an EMR.

(Neehr Perfect® networked educational EHR featuring World VistA. Courtesy of Archetype Innovations, LLC 2010).
3. Problems, Interventions, Evaluation (PIE) model
 This system consists of a client care assessment flow sheet and progress notes.

Flow sheet - uses specific assessment criteria in a particular format, such as human
needs or functional health patterns.

For example, a client’s blood pressure may be monitored by the minute, whereas in an
ambulatory clinic a client’s blood glucose level may be recorded once a month. After the

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assessment, the nurse establishes and records specific problems on the progress notes,
often using NANDA diagnoses to word the problem.

NANDA International’s three-part format:

(1) client’s response,
(2) contributing or probable causes of the response, and
(3) characteristics manifested by the client

 The PIE system eliminates the traditional care plan and incorporates an ongoing care plan
into the progress notes. Therefore, the nurse does not have to create and update a separate
plan. A disadvantage is that the nurse must review all of the nursing notes before giving care
to determine which problems are current and which interventions were effective.

4. Focus Charting - is intended to make the client concerns and strengths the focus of care.
Three columns for recording are usually used: date and time, focus, and progress notes.
The focus may be a condition, a nursing diagnosis, a behavior, a sign or symptom, an acute
change in the client’s condition, or a client strength. The progress notes are organized into;
Focus on the client’s care.
Data - reflects the assessment phase of the nursing process and consists of
observations of client status and behaviors, including data from flow sheets
(e.g., vital signs, pupil reactivity). The nurse records both subjective and
objective data in this section.
Action - reflects planning and implementation and includes immediate and future
nursing actions. It may also include any changes to the plan of care.
Response -reflects the evaluation phase of the nursing process & describes the
client’s response to any nursing and medical care.
 The focus charting system provides a holistic perspective of the client and the client’s needs.
It also provides a nursing process framework for the progress notes (DAR). Flow sheets and
checklists are frequently used on the client’s chart to record routine nursing tasks and
assessment data.
Date/Hour Focus Progress Notes
Oct 19, 2020 Pain D: Guarding abdominal incision.
07:00 am Facial grimacing.
Rates pain at “8” on scale of 0–10.
A: Administered morphine sulfate 4 mg IV. 0930
R: Rates pain at “1.” States willing to ambulate.
5. Charting by Exception (CBE)
 is a documentation system in which only abnormal or significant findings or
exceptions to norms are recorded.
a. Flow sheets.
For examples; graphic record, fluid balance record, daily nursing assessments record,
client teaching record, client discharge record, and skin assessment record. b.Standards
of nursing care.
 The standards of nursing practice eliminates repetitive charting of routine care.
 An agency must develop its own specific standards of nursing practice that identify
the minimum criteria for client care regardless of clinical area.
 Some units may also have unit-specific standards unique to their type of client. For
example, “The nurse must ensure that the unconscious client has oral care at least
q4h.” Documentation of care according to these specified standards involves only a
check mark in the routine standards box on the graphic record. If all of the standards
are not implemented, an asterisk on the flow sheet is made with reference to the
nurses’ notes.

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 All exceptions to the standards are fully described in narrative form on the nurses’
notes.
 All flow sheets are kept at the client’s bedside to allow immediate recording and to
eliminate the need to transcribe data from the nurse’s worksheet to the permanent
record.
 The advantage to this system is the elimination of lengthy, repetitive notes and it
makes client changes in condition more obvious.
 Inherent in CBE is the presumption that the nurse did assess the client and
determined what responses were normal and abnormal.
 Many nurses believe in the saying “not charted, not done” and subsequently may
feel uncomfortable with the CBE documentation system.
 One suggestion is to write N/A on flow sheets where the items are not applicable
and to not leave blank spaces. This would then avoid the possible misinterpretation
that the assessment or intervention was not done by the nurse.

Sample of a portion of a daily nursing CBE assessment form used in an EMR.

(Neehr Perfect® networked educational EHR featuring WorldVistA. Courtesy of Archetype Innovations, LLC 2010)

6. Computerized Documentation
Electronic Health Records are used to manage the huge volume of information required
in contemporary health care. Nurses use computers to store the client’s database, add new
data, create and revise care plans, and document client progress.
 All pertinent client’s information are recorded.
 The information can be easily retrieved in a variety of formats.
 Computers make care planning and documentation relatively easy.
 To record nursing actions and client responses, the nurse either chooses from
standardized lists of terms or types narrative information into the computer.
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 Automated speech-recognition technology now allows nurses to enter data by voice
for conversion to written documentation.

 The Nursing Minimum Data Set (NMDS) is an effort to establish uniform definitions and
categories (e.g., nursing diagnoses) for collecting, essential nursing data for inclusion in
computer databases.

Pros and Cons of Computer Documentation

PROS CONS
■ Computer records can facilitate a focus on client outcomes. ■ Client’s privacy may be
■ Bedside terminals can synthesize information from monitoring equipment. infringed on if security measures
■ It allows nurses to use their time more efficiently. are not used.
■ The system links various sources of client information. ■ Breakdowns make information
■ Client information, requests, & results are sent & received quickly. temporarily unavailable.
■ Links to monitors improve accuracy of documentation. ■ The system is expensive. ■
■ Bedside terminals eliminate the need to take notes on a worksheet before Extended training periods may
recording. be required when a new or
■ Bedside terminals permit the nurse to check an order immediately before updated system is installed.
administering a treatment or medication.
■ Information is legible.
■ The system incorporates and reinforces standards of care.
■ Standard terminology improves communication.
8. Case Management

 Emphasizes quality, cost-effective care delivered within an established length of stay.

 Use a multidisciplinary approach to planning and documenting client care, using critical
pathways.
 These forms identify the outcomes that certain groups of clients are expected to achieve on
each day of care, along with the interventions necessary for each day.
 Promote collaboration and teamwork among caregivers, helps to decrease length of stay,
and makes efficient use of time. Because care is goal focused, the quality may improve.
However, critical pathways work best for clients with one or two diagnoses and few
individualized needs.
 In this case management model incorporates graphics and flow sheets. Progress notes
typically use some type of charting by exception.

For example, if goals are met, no further charting is required. A goal that is not met is called a
variance. A variance is a deviation from what was planned on the critical pathway— unexpected
occurrences that affect the planned care or the client’s responses to care. When a variance
occurs, the nurse writes a note documenting the unexpected event, the cause, and actions taken
to correct the situation or justify the actions.

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Kozier & Erbs (2018) , Fundamentals of Nursing Practice

Documenting Nursing Activities

1. Admission Nursing Assessment - referred to as an initial database, nursing history, or nursing
assessment, is completed when the client is admitted to the nursing unit.
 these forms can be organized according to health patterns, body systems, functional abilities,
health problems and risks, nursing model, or type of health care setting.

2. Kardex - is a widely used, concise method of organizing and recording data about a client,
making information quickly accessible to all health professionals.
 Kept in a portable index file or on computer-generated forms.
 Quickly accessed to reveal specific data.
 A temporary worksheet written in pencil for ease in recording frequent changes in details of a
client’s care.
 The information on Kardexes may be organized into sections, for example:
■ Pertinent information about the client, such as name, room number, age, admission
date, primary care provider’s name, diagnosis, and type of surgery and date
■ Allergies
■ List of medications, with the date of order and the times of administration for each ■
List of intravenous fluids, with dates of infusions
■ List of daily treatments and procedures, such as irrigation, dressing changes, postural
drainage, or measurement of vital signs
■ List of diagnostic procedures ordered, such as x-ray or laboratory tests
■ Specific data on how the client’s physical needs are to be met, such as type of diet,
assistance needed with feeding, elimination devices, activity, hygienic needs, and
safety precautions (e.g., one-person assist)
■ A problem list, stated goals, and a list of nursing approaches to meet the goals and
relieve the problems.

3. Flow Sheets - enables nurses to record nursing data quickly and concisely and provides an
easy-to-read record of the client’s condition over time.
 Graphic Record - Indicates body temperature, pulse, respiratory rate, blood pressure, weight,
and, in some agencies, other significant clinical data such as admission or postoperative day,
bowel movements, appetite, and activity.
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 Intake and Output Record - All routes of fluid intake and all routes of fluid loss or output are
measured and recorded on this form.

4. Medication Administration Record usually include date of the medication order, the
expiration date, the medication name and dose, the frequency of administration and route, and
the nurse’s signature.

5. Skin Assessment Record - A flow sheet for skin or wound assessment. These records
may include categories related to stage of skin injury, drainage, odor, culture information, and
treatments.

6. Progress Notes - made by nurses provide information about the progress a client is
making toward achieving desired outcomes. Therefore, in addition to assessment and
reassessment data, progress notes include information about client problems and nursing
interventions. The format used depends on the documentation system in place in the institution.

7. Nursing Discharge/ Referral Summaries - are completed when the client is being
discharged and transferred to another institution or to a home setting where a visit by a
community health nurse is required.

 The discharge plan, including instructions for care, and the final progress note.
For example, medications, treatments, and activities should be written in layman’s terms, and use
of medical abbreviations (such as ad lib) should be avoided. If a client is transferred within the
facility or from a long term facility to a hospital, a report needs to accompany the client to ensure
continuity of care in the new area.

 Any teaching or client instruction that has been done should also be described and recorded.
If the client is being transferred to another institution or to a home setting where a visit by a
home health nurse is required, the discharge note takes the form of a referral summary.

Discharge and Referral Summaries usually include some or all of the following:
■ Description of client’s physical, mental, and emotional status at discharge or transfer.
■ Resolved health problems.
■ Unresolved continuing health problems and continuing care needs; may include a reviewof-
systems checklist.
■ Treatments that are to be continued (e.g., wound care, oxygen
therapy) ■ Current medications.
■ Restrictions that relate to (a) activity such as lifting, stair climbing, walking, driving, work; (b) diet;
and (c) bathing such as sponge bath, tub, or shower.
■ Functional/self-care abilities in terms of vision, hearing, speech, mobility with or without aids,
meal preparation and eating, preparing and administering medications.
■ Comfort level.
■ Support networks including family, significant others, religious adviser, community selfhelp
groups, home care and other community agencies available.
■ Client education provided in relation to disease process, activities and exercise, special diet,
medications, specialized care or treatments, follow-up appointments.
■ Discharge destination (e.g., home, nursing home) and mode of discharge (e.g., walking,
wheelchair, ambulance)
■ Referral services (e.g., social worker, home health nurse).

Long-Term Care Documentation Two

types of care:
1. Skilled Care - require more extensive nursing care and specialized nursing skills.
2. Intermediate Care - focus is needed for clients who usually have chronic illnesses and may
only need assistance with activities of daily living (such as bathing and dressing).
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Guidelines/ Protocols/ Tools in Documentation related to Client
 Home Care Documentation In 1985 the Health Care Financing Administration, a branch of
the U.S. Department of Health and Human Services, mandated that home health care
agencies standardize their documentation methods to meet requirements for Medicare and
Medicaid and other third-party disbursements.
 Two records are required: (a) a home health certification and plan of treatment form and (b) a
medical update and client information form.
 The nurse assigned to the home care client usually completes the forms, which must be
signed by both the nurse and the attending primary care provider.
 Some home health agencies provide nurses with laptop or handheld computers to make
records available in multiple locations. With the use of a modem, the nurse can add new
client information to records at the agency without traveling to the office.

General Guidelines for Recording - client’s record is a legal document and may be used to
provide evidence in court, many factors are considered in recording.
1. Health care personnel must not only maintain the confidentiality of the client’s record but also
meet legal standards in the process of recording.
2. Document date and time of each recording.
3. Legibility - all entries must be legible and easy to read to prevent interpretation errors.
4. Permanence - all entries on the client’s record are made in dark ink so that the record is
permanent and changes can be identified. Dark ink reproduces well on microfilm and in
duplication processes.
5. Accepted Terminology Abbreviations - are used because they are short, convenient, and easy
to use.
6. Correct Spelling - is essential for accuracy in recording.
7. Signature - With computerized charting, each nurse has his or her own code, which allows the
documentation to be identified.
8. Accuracy - client’s name and identifying information should be stamped or written on each
page of the clinical record. Before making any entry, check that it is the correct chart. Do not
identify charts by room number only; check the client’s name.
9. Completeness
10. Sequence
11. Appropriateness
12. Conciseness
13. Legal Prudence - complete documentation should give legal protection to the nurse, the
client’s other caregivers, the health care facility, and the client. Admissible in court as a legal
document, the clinical record provides proof of the quality of care given to a client.
Documentation is usually viewed by juries and attorneys as the best evidence of what really
happened to the client.

The Purpose of Reporting

 is to communicate specific information to a person or group of people.
 oral or written, should be concise, including pertinent information but no extraneous detail.
 the sharing of information or ideas with colleagues and other health professionals about
some aspect of a client’s care.
For examples include the care plan conference and nursing rounds.

Telephone Reports
 Nurses inform primary care providers about a change in a client’s condition; a radiologist
reports the results of an x-ray study; a nurse may report to a nurse on another unit about a
transferred client. The nurse receiving a telephone report should document the date and time,
the name of the person giving the information.

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Sample SBAR Communication Tool

Telephone Orders
 primary care providers often order a therapy (e.g., a medication) for a client by telephone.
 Many agencies allow only registered nurses to take telephone orders. While the primary care
provider gives the order, write the complete order down on the physician’s order form and
read it back to the primary care provider to ensure accuracy.
 The primary care provider verbally acknowledge the read-back of the verbal/ telephone order.
Then indicate on the physician’s order form that it is a verbal order (VO) or telephone order
(TO).
 Once the order is written on the physician’s order form, the order must be countersigned by
the primary care provider within a time period described by agency policy. Many acute care
hospitals require that this be done within 24 hours.

Guidelines for Telephone and Verbal Orders

Care Plan Conference

 is a meeting of a group of nurses to discuss possible solutions to certain problems of a client,
such as inability to cope with an event or lack of progress toward goal attainment.
 allows each nurse an opportunity to offer an opinion about possible solutions to the problem.
 most effective when there is a climate of respect—that is, nonjudgmental acceptance of
others even though their values, opinions, and beliefs may seem different. Nurses need to
accept and respect each person’s contribution.
Nursing Rounds - are procedures in which two or more nurses visit selected clients at each
client’s bedside to:
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■ Obtain information that will help plan nursing care.
■ Provide clients the opportunity to discuss their care. ■
Evaluate the nursing care the client has received.

During rounds, the nurse assigned to the client provides a brief summary of the client’s
nursing needs and the interventions being implemented. Nursing rounds offer advantages to both
clients and nurses: Clients can participate in the discussions, and nurses can see the client and
the equipment being used. To facilitate client participation in nursing rounds, nurses need to use
terms that the client can understand.

Pre - test I.
Multiple Choice. Write the correct letter.
1. When initiating the implementation phase of the nursing process, the nurse performs which of
the following phases first?
a. Carrying out nursing interventions
b. Determining the need for assistance
c. Reassessing the client
d. Documenting interventions

2. Under what circumstances is it considered acceptable practice for the nurse to document a
nursing activity before it is carried out?
a. When the activity is routine (e.g., raising the bed rails)
b. When the activity occurs at regular intervals (e.g., turning the client in bed)
c. When the activity is to be carried out immediately (e.g., a stat medication)
d. It is never acceptable

3. The primary purpose of the evaluating phase of the care planning process is to determine
whether;
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a. Desired outcomes have been met.
b. Nursing activities were carried out.
c. Nursing activities were effective.
d. Client’s condition has changed.

4. The client has a high-priority nursing diagnosis of Risk for Impaired Skin Integrity related to the
need for several weeks of imposed bed rest. The nurse evaluates the client after 1 week and
finds the skin integrity is not impaired. When the care plan is reviewed, the nurse should perform
which of the following?
a. Delete the diagnosis since the problem has not occurred.
b. Keep the diagnosis since the risk factors are still present.
c. Modify the nursing diagnosis to Impaired Mobility.
d. Demote the nursing diagnosis to a lower priority.

5. If the nurse planned to evaluate the length of time clients must wait for a nurse to respond to a
client need reported over the intercom system on each shift, which process does this reflect?
a. Structure evaluation
b. Process evaluation
c. Outcome evaluation
d. Audit

6. Which of the following is true regarding the relationship of implementing to the other phases of
the nursing process?
a. The findings from the assessing phase are reconfirmed in the implementing phase.
b. After implementing, the nurse moves to the diagnosing phase.
c. The nurse’s need for involvement of other health care team members in implementing occurs
during the planning phase.
d. Once all interventions have been completed, evaluating can begin.

7. The care plan calls for administration of a medication plus client education on diet and
exercise for high blood pressure. The nurse finds the blood pressure extremely elevated. The
client is very distressed with this finding. Which nursing skill of implementing would be needed
most?

a. Cognitive
b. Intellectual
c. Interpersonal
d. Psychomotor

8. Which of the following demonstrates appropriate use of guidelines in implementing nursing

interventions? Select all that apply.
a. No interventions should be carried out without the nurse having clear rationales.
b. Always follow the primary care provider’s orders exactly, without variation.
c. Encourage all clients to be as dependent as desired and allow the nurse to perform care for
them.
d. When possible, give the client options in how interventions will be implemented.
e. Each intervention should be accompanied by client teaching.

9. Which of the following represents application of the components of evaluating?

a. Goal achievement must be written as either completely met or unmet.
b. Data related to expected outcomes must be collected.
c. If the outcome was achieved, conclude that the plan was effective.
d. After determining that the outcome was not met, start over with a new nursing care plan.

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10. An element of quality improvement, rather than quality assurance, is which of the following?
a. Focus is on individual outcomes
b. Evaluates organizational structures
c. Aims to confirm that quality exists
d. Plans corrective actions for problem.

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