According to

orientation
program 2015-2016
Mustafa Al-Ajouli
Present

Documentation
Guideline for Nurses
19-1-2016

Documentation
Guideline for Nurses

The Code of Ethics for Registered Nurses

(CNA, 2008). According to the Standards1 ,
each registered nurse is expected to
complete written and/or electronic
documentation in a manner that is clear,
timely, accurate, comprehensive, legible,
chronological, and is reflective of relevant
. observations

.The goals

After completion of Documentation

Guideline for Nurses, the participant will be
:able to
Explain the importance of documentation as . 1
a health care provider
Identify the basic information that is required . 2
when, how, and what documenting in the
.medical record
.Determine documentation Do's and Don'ts -3
Identify the methods of documentation - 4


Objectives

Introduction
Documentation

Principles

Benefits
What , when, and how to chart
Methods of documentation

Critical points
Telephone order

Kardex
Recommendation

Definitions

Documentation is anything written or

electronically generated that describes the
status of a client or the care or services
given to that client (Perry, A.G., Potter, P.A.,
. 2010)
Nursing documentation refers to written or
electronically generated client information
obtained through the nursing process
.(ARNNL, 2010)
Documentation is an integral part of nursing
practice and professional patient care
rather than something that takes away from
.patient care

Good documentation has six important

:characteristics. It should be

Factual- 1

Accurate-2.

Complete- 3

Current (timely)- 4

Organized- 5
Compliant with standards (Potter &-6
. Perry,2010 p212)

Why should RNs

?document
Clear, complete and accurate health records
serve many purposes for clients, families,
registered nurses and other care providers.
:-Data from documentation allows for
Communication and Continuity of Care*
Quality Improvement/Assurance and Risk*
Management
* Establishes Professional Accountability

* Legal Reasons
* Expanding the Science of Nursing

Benefits
Continuity of care tool
Pt protection device
Quality management aid
Legal safety net
A patient chart is a legal document
Any documintation on the pt chart
is permenant

signs and symptoms. 1.

Your observations. 2.
All injuries, illnesses and unusual health . 3
. situations
Response to a medication or treatment. 4.
.All appointments and consultations. 5
New symptoms or conditions. 6.
Routine, ongoing treatments or conditions. 7.
Any action you take in response to an. 8.
individual's problem
As a general rule, do not chart actions. 9
. completed by others

when to chart

.After nursing implementing shift to shift walking round -1

Check that you have the correct chart before you writing -2
.then start charting
On admission, transfer to other ward, sending and coming -3.
.from O.R. and discharge
Chart what an important data after visits by physicians or -4
other members of the health care team such as the
. dietician, social worker, etc
. After consultation-5

when
Chart as soon as possible after giving-6
care; don't wait to chart until the end of
your work day
Never document medications , treatments-7
or procedure before they are given or

.completed

Narrative:- takes the form of a story written in- 1

.paragraphs
Charting(
SOAP/SOAPIER-2
SUBJECTIVE,OBJECTIVE, ASSESSMENT, PLAN,
INTERVENTION,EVALUATION,REVESION
Problem, Intervention, Evaluation))3-PIE
Charting
Data, Action, Respons)) Charting 4-DAR

Clearly
,Comprehensively
Completely
Accurately
Honestly&

.Date and time each entry. 1

2. All record should be written in
permanent ink .
Do not leave blank lines between entries. 3.
Use only abbreviations and symbols. 4
. approved in agency policies
5. All records should be written
objectively and without bias, personal
opinion, or value judgment.
6. Documentation should be clear, concise,
and specific.
7. Don't use vague terms.

Check that you have the correct chart -13

.before you begin writing
Make sure your documentation reflects -14
the nursing process and your professional
.capabilities
If you remember an important point after - 15
you've completed your documentation,
chart the information with a notation that
it's a "late entry." Include the date and
.time of the late entry

.Don't chart your opinions- 15

Don't use words associated with errors or ones that - 16
suggest that the patient's safety was in danger such
as: "by mistake," "accidentally," "unintentionally,"
."miscalculated," "confusing
Correct Spelling, is essential for accuracy in - 17
recording. Incorrect spelling gives a negative
impression to the reader and, thereby, decreases the
nurses credibility
.Chart often enough to tell the whole story-18
When documentation continues from one page to-19
the next, sign the bottom of the first page. At the top
of the next page, write the date, time and "continued
from previous page." Make sure each page is
.stamped with the client's identifying information

Several principles apply to all charting methods

""If it isn't charted, it's not done
Timeliness is important: chart as care is provided,
do not wait until the end of shift to record the
days work
Charts are legal documents and should be
accurate, concise, and complete
Never chart prior to actually performing care (ie
don't chart medications given until the patient
actually takes them)
Use straightforward language: provide accurate
measures ("ate 90% of dinner" not "ate well")
Provide objective information; avoid subjective
observations and assumptions
Avoid use of personal comments or judgements
Refer to each institution's policies and procedures
for specific information

Include the following information

when documenting nursing
procedures:
What procedure was performed
When it was performed
Who performed it
How it was performed
How well the client tolerated it

Write down the time and date on the physicians

.
order sheet
Write down the order exactly as given by the
.physician
Read the order back to the physician to ensure it is
.accurately recorded
;Record the physicians name on the order sheet
state telephone order; print your name and
.,sign the entry, along with your designation (e.g
(.RN
On-site verbal orders also have the potential for
error and should be avoided except in urgent or
,emergency situations (e.g., cardiac arrest). Again
nurses need to be aware of agency policy related to
.accepting and documenting on-site verbal orders

A summary worksheet reference

of basic information that
traditionally is not part of the
:record. Usually contains
Client data (name, age, file No., date of -
.admission)
.Medical diagnoses: listed by priority -

.Allergies.-Medical orders (diet, IV therapy, etc.) -

Activities permitted. lab test, non wight-
,bearing