DOCUMENTING THE HEALTH HISTORY,

PHYSICAL EXAMINATION FINDINGS, AND

DEVELOP NURSING CARE PLAN IN RELATION
TO:
ELDERLY CASE

_ Framita Rahman_
Define d o c u m e n t a t i o n in N u r s i n g
Practice

• Documentation in Nursing Practice is anything written or

electronically generated that describes the status of client on the
care or services given to that client (Perry, A/ G., Potter, P.A. , 2010)

• Nursing documentation refers to written or electronically client

information obtained through the nursing process, (Associationof
Registered Nurses of Newfoundland and Labrador , 2010)

• Document is an integral part of nursing practice and professionalof

nursing care rather than something that takes away from patient
care.

• Document is not optional.

Core principles o f effective
d o c u m e n t a t i o n in Nursing
Practice

Nursing documentation must provide an accurate

and honest account of and what events occurred as
well as identify who provided the care.
Good documentation has 6 important
characteristics.
• Descriptive objective information about what the
nurse sees, hears, feels, smells and think

• Vague terms like seem or apparently

• Includes objective signs of problems

• Subjective data is documented in client’s exact

words within quotation marks
• Use of exact measurement establishes accuracy

• e.g. Intake of 400ml of water thenwriting

adequate amount of water
• Condition change

• Patient’s responses especially unusual, undesired or

ineffective response.

• Communication with patient family

• Entries in all spaces on all relevant assessment form. Use

N/A or other designation per policy for items that do apply
to your patient.
N/A
• Do not leave blank
• Document date & timeof each recording

• Record time in conventional manner (e.g. 9:00am to

6:00pm or according to the 24 hoursclock)

• Avoid recording in advance (this practice is illegal

falsification of the records contributes to errorsand
confusion and threatens patient safety.

• Client’s name, the word can be omitted

• Recording need to be brief as well as complete to
save time and communication
• Using black pen, clear enough to be
read, readable particularly handwriting

• Any mistakes occur while recording draw a line

through it and write above or next to originalentry
with your initial or name.
CASE
A 78-year-old man lives at home with his 70-year-old wife.
Clients live on stilts. Thecommunity health nurse came to
the client's house and found that grandfather was sick with
a fever accompanied by coughing, his wife said the client
had not been given medicine. The results of the
temperature assessment were 39 ° C, felt warm, and
looked coughing, breathing 16 x / min, TD 110/70 mmHg,
dry lips, and the client looked thin. Coughing up phlegm,
since 4 days ago, heard the sound of Rhonchi.