Documentation

Rashid Hussain Nursing Instructor RMI-SON

3/31/2013

ACN

1

Objectives
 Define

nursing documentation (ND)  Purpose of ND  Advantage of nursing documentation  Principle of ND  Example of inaccurate & accurate ND  Different record keeping documents.  Consequences of inaccurate ND
3/31/2013 2

3/31/2013 3 . Accurate record keeping and careful documentation is an essential part of nursing practice.Nursing Documentation Any written or electronically generated information about a client that describes the care or service provided to that client.

3/31/2013 4 .  Information reported to a physician or other health care provider. and the impact of these interventions on client outcomes.Nursing documentation clearly describes:  An assessment of the client’s health status. nursing interventions carried out.

Purpose for documentation        To facilitate communication To promote good nursing care To meet professional and legal standards Satisfaction of Legal and Practice standards Education Research Reimbursement 3/31/2013 5 .

Benefits of the Nursing Notes Nursing documentation provides:  An account of judgment  Critical thinking used in the nursing process. 3/31/2013 6 .

& agency standards  Enhance nursing care  Facilitate communication b/w nurses & other health care providers. legislative. 3/31/2013 7 .Cont… Accurate. timely documentation reflects care provided:  Professional.

Cont… It also reflects the application of :  Nursing knowledge  Nursing skills & judgment  Established accountability  Conveys the unique contribution of the nursing to health care 3/31/2013 8 .

.  Abbreviations and Symbols  Use only authorized abbreviations and symbols.  Legibility  Writings must be easily readable. without any chance of error.PRINCIPLES OF EFFECTIVE DOCUMENTATION  Use of Common Vocabulary  Use of common vocabulary improve intrateam communication and lessen the chance of misunderstandings.

descriptive terms to chart exactly what was observed or done. Use correct spelling and grammar. . Chart in a chronological order  Accuracy  Use factual. and write complete sentences.PRINCIPLES OF EFFECTIVE DOCUMENTATION  Organization  Start every entry step by step with the date and time.

The client records should not be with unconcerned personnel . Document the error in the nurses’ notes  Confidentiality  Nurses are bound by ethical codes and laws to treat all client information in a confidential and professional manner.PRINCIPLES OF EFFECTIVE DOCUMENTATION  Documenting a an Error  Facilities require nurses to report errors on incident reports.

Guidelines For Documentation  Factual  Accurate  Complete  Current  Organized 3/31/2013 12 .

How to writ nurses’ notes A = Airway  B = Breathing  C = Circulation  D = Drainage  E = Eliminations  F = Fluids  G = GCS 3/31/2013 13 .

Continue same RX. 3/31/2013 14 . no any further order. X received from morning staff in well condition. eating well. Vital signs checked & recorded. Physician checked the pt.Inaccurate Example Mr. Well oriented.

received from Night shift. stool passed normally.________ A. RR=20/m. X.Accurate Example Mr. Breathing spontaneously on room air.P 110/ 70mmgh. IV fluids 100ml / hr continue for 24 hrs. catheter in placed urine output 30ml/hr. place & person. pulse=80/m. B. 3/31/2013 15 . Oriented to time. chest tube in placed with bubbling & column movement present.Razzak.

Record Keeping Forms  Nursing history (HX)  Graphic or flow sheet  Medication administration record  Nursing KARDEX  Standardized care plans  Discharge summary 3/31/2013 16 .

Methods of Documentation  Narrative Charting  Source-oriented charting  Problem-oriented charting  PIE charting  Focus charting  Charting by exception  Computerized documentation  Critical pathways .

Narrative Charting  This traditional method of nursing documentation takes the form of a story written in paragraphs. . this was the only method for documenting care.  Before the advent of flow sheets.

Source-Oriented Charting  A narrative recording by each member (source) of the health care team on separate records. .

Problem-Oriented Charting  Focuses on the client’s problem and       employs a structured. logical format called SOAPIE charting: S: Subjective data (what the client states) O: Objective data (what is observed/inspected) A: Assessment P: Plans I: Intervention E: Evaluation .

PIE Charting PROBLEM INTERVENTION EVALUATION .

and response (DAR). action. .Focus Charting  A documentation method that uses a column format to chart data.

.Charting by Exception  A documentation method that requires the nurse to document only deviations from pre-established norms.

Computerized Documentation: Advantages  Decreased documentation time.  Enhanced implementation of the nursing process. and concise words.  Enhanced decision making.  Statistical analysis of data.  Multidisciplinary networking. .  Clear. decisive.  Increased legibility and accuracy.

Consequences Of Inadequate Documentation  Fragmented care  Repetition of tasks  Delayed therapy  Omitted therapy  Delayed recovery 3/31/2013 25 .

. L. Esson. 480 3/31/2013 26 . (1999). Nursing Foundation: A Canadian Perspective. B. & Ronaldson. Scarborough: Prentice Hall Canada. P. S.Refrences  DUGas.

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