NURSING

DOCUMENTATION

by Abdul Azis
 DOCUMENTATION

Documentation is a set of documents

provided on paper, or online, or on digital
or analog media, such as audio tape or
CDs.
DOCUMENTATION
 NURSING
 Nursing is the protection, promotion, and
optimization of health and abilities,
prevention of illness and injury,
alleviation of suffering through the
diagnosis and treatment of human
response, and advocacy in the care of
individuals, families, communities, and
populations.”
 Nursing Documentation
 Nursing documentation is essential for
good clinical communication. Appropriate
legible documentation provides an accurate
reflection of nursing assessments, changes
in conditions, care provided and pertinent
patient information to support the
multidisciplinary team to deliver great care.
Documentation provides evidence of care
and is an important professional and
medico legal requirement of nursing
practice.
 Definition of Terms
Documentation: encompasses all written and/or
electronic entries reflecting all aspects of patient
care communicated, planned recommended or
given to that patient.
‘End of shift’ progress notes: nursing
documentation written as a summary at the end or
towards the end of shift.
‘Real time’ progress notes: nursing
documentation written in a timely manner during
the shift.
 Definition of Terms
 ISBAR: (Identify, Situation, Background,
Assessment, Recommendation) framework for
clinical communication
Admission assessment: Comprehensive
nursing assessment including patient history,
general appearance, physical examination and
vital signs completed at the time of admission.
Shift assessment: Concise nursing assessment
completed at the commencement of each shift or
if patient condition changes at any other time
during your shift.
 NURSING DOCUMENTATION
 Health history information,chief complaint
(major element of complaint)
 Physical examination and diagnostic test
information
 Functional health pattern
(Breathing,nutrition,sleep,rest,comfort)
 Analysis of data
(problem list,need for nursing care)
 Summary of patient problem(skin
problem,special diet needs)
 Formulation of nursing diagnosis
Case history
Mrs.Jane Jhonson,25 years old,Chatolic,
address Jl.Kecak 25 Denpasar,complaint of
pain when passing water,passed a small
amount,there was a lot of blood with cloth.
She feel pain on the suprapubic area and she
did not feel fever after taken septrin tablet but
she felt a few days ago.
She often go to the lavatory cause
this problem. She got this problem
since she had children. She had two
children : Five and six, her complain
worse since her second. She a
forceps delivery history, she wonder
if it is the coil. She used three years
and she had it strait away after.
She is under family planning
clinic,she choosed coil instead pill
because she got migraine. She think
there is not any connection between
attacks and intercourse. Her body
weight steady and her appetite is
very poor.
Her bowel regular. She lose 4 days
every 28 days period,she smoke thirty
a day,drink only at weekends,Family
history : her mother and her sister has
this problem and take some tablet.
 Doctor advise :
- She must have kidney and bladder X-ray
 Physical Examination :
- Thin long limbed healthy girl
- Not Anaemic
 O/E : C V S P : 80 x/minute
Ht : not enlarged
Ht : normal sounds
BP : 130/90 mmHg
 Laboratory Finding : Urine routine
Urine sedimen :
- Leukocyte : 100-150 (0-5)
- Bacteria : ++++ (- )
- Blood : +++ (- )
 X Ray Finding : Normal x ray result
 Medical diagnosis : Recurent UTI
 Threatment :
- Bactrim Forte 2 x 1
- Mefenamic acid 500 mg 3 x 1 prn
 Useful Question

 Could you tell me your complete name?

 What is your chief complaint?
 What’s your religion?
 Do You smoke?
 Are you feverish?
 Doyou drink alcohol?
 Have you stopped smoking?
 Could you tell me about your family?
 Useful Question
 How many brothers and sisters do you have?
 Are you married?
 What is your father’s name?
 Have you ever suffered from certain diseases?
 Are you allergic to certain foods?
 How are you bowel habits?
 What about your bladder habits?
 Do you pass water frequently?
 Are you pregnant?
 VOCABULARY

 Antibiotic
 Antifungal

 Antivirus
 Antispasmodic

 Antidiuretic
 Antidepresant
 Antipyretic

 Antipruritic

 Antihelmintic
 Bronchodilator

 Cough medicine
Practice
No llness/Pain First Aid/Medicine
1 Migrain
2 Sprained ankle
3 Food poisoning
4 Fever
5 Heart Attack
6 Hypertension
7 Asthma
8 Earache
9 Convulsion
10 Cough
 GRAMMAR FOCUS
1. Menyatakan lebih suka terhadap suatu
benda
Pola 1 :
S + Like + Noun + Better than + noun
Example : Jane like apple better than grape
Pola 2 :
S + Prefer + Noun + To + noun
Example : Jane prefer apple to grape
Pola 3 :
S + Prefer + To Infinitive + rather than +
Infinitive/Gerund/noun
Example :
Jane prefer to eat apple rather than eating grape
Pola 4 :
S + Would Rather+ Infinitive + than +
Infinitive/Gerund/noun
Example :
Jane would rather eat apple than grape
Grammar focus
2. Meminta seseorang melakukan sesuatu
secara halus
Pola :
S + prefer + Someone(subject) + To Infinitive
Example :I Prefer he to go to bed
3. Comparison of Equality
As + Adjective + as
- Open your mouth as wide as you can
- Put your tongue as far as you can
- Breathe as deeply as you can
- Take as much exercise as possible
NURSING DOCUMENTATION
EXERCISE
 CONCLUSION
 Personal data
 Medical History
 Functional health pattern
 Analysis of data
 Nursing Diagnosis
 Nursing Intervention and Evaluation
 Nursing Summary