NURSING DOCUMENTATION

COURSE

MS. MARIANNE LAYLO

Head, Nursing Education
NURSINGDOCUMENTATION
NURSING DOCUMENTATION
• Also known as reporting, charting or recording
• serves as a permanent record of patient
information and care
• is a written record of patient’s progress and
nursing care provided utilizing the nursing
process
WHYAADOCUMENTATION
WHY DOCUMENTATIONCOURSE?
COURSE?

• Reasons why this course is needed:

• Frequently requested
• Audits show serious deficiencies
 DOCUMENTATION COURSE
DOCUMENTATION COURSE
CONTENTS
CONTENTS
• Reasons why this course is needed:
• Frequently requested
• Audits show serious deficiencies
 INTRODUCTION
INTRODUCTION
• Documentation is one of the main communication tools that
health care providers use to exchange client information
• Documentation is now defined as any written or electronic information or data about
client interactions or care events that meet both professional AND legal standards.
Legal standards refer to how your documentation will be examined by the courts.
COMMONDEFICIENCIES
COMMON DEFICIENCIES
• Illegible or messy handwriting
• Inappropriate signature
• Failure to record significant health or medication
information
• Failure to document a discontinued medication or
treatment.
NARRATIVECHARTING
NARRATIVE CHARTING
• This  is  the most familiar method  of documenting nursing 
care
• It  is  a diary or story format  in  chronological order.
• It  is  used to document  the patient's status, care, events,
treatments, interventions, and patient's response to the
interventions.
NARRATIVECHARTING
NARRATIVE CHARTING
• This  is  the most familiar method  of documenting nursing 
care
• It  is  a diary or story format  in  chronological order.
• It  is  used to document  the patient's status, care, events,
treatments, interventions, and patient's response to the
interventions.
POLICY ON
POLICY ON ERROR
ERROR

Draw a single line with the word “Error” printed

above, staff nurse signature and job number
POLICYON
POLICY ONLATE
LATEENTRY
ENTRY

Identify the Late Entry by writing Late Entry and

include the date and time when it was written and the
estimated/exact time when the even occurred
 Writeyour
Write yourname,
name,signature
signatureand
andjob
jobnumber
numberlegibly
legibly
whenclosing
when closingyour
yournotes
noteson
onthe
thelast
lastline
lineofofthe
thepage.
page.
 Writeyour
Write yourname,
name,signature
signatureand
andjob
jobnumber
numberlegibly
legibly
whenclosing
when closingyour
yournotes
noteson
onthe
thelast
lastline
lineofofthe
thepage.
page.
RE-ASSESSMENT
RE-ASSESSMENT
RE-ASSESSMENT
Identify your reassessment by writing the word
“reassessment” followed by the data.
Identify your reassessment by writing the word
“reassessment” followed by the data.
 MULTIDISCIPLINARY
MULTIDISCIPLINARY
PLANOF
PLAN OFCARE
CARE

Stamp and
• airway management
• pain management
Signature
SPECIFIC
• functional assessment MEASURABLE
Interventions
should be
of Treating
• discharge planning appropriate to the team
ATTAINABLE
• nutritional assessment diagnosis or
REALISTIC problem and are within 24
• psychological support TIME BOUNDED documented.
• safe environment hours
• hemodynamic monitoring
• blood sugar monitoring
• infection prevention
• pressure ulcer prevention
and/or management

UPON ADMISSION
• airway management
• pain management
• functional assessment
• discharge planning
• nutritional assessment
• psychological support
• safe environment
• hemodynamic monitoring
• blood sugar monitoring
• infection prevention
• pressure ulcer prevention and/or
management
Interventions should be appropriate
to the diagnosis or problem and are
documented.
Stamp and Signature of Treating
team within 24 hours
• Sample with stamp

FOR REFERENCE ONLY

NURSING EDUCATION DEPARTMENT 30122018
NURSINGCARE
NURSING CAREPLAN
PLAN
WHENTO
WHEN TOWRITE
WRITENCP?
NCP?
• Every Shift
• Upon Admission
• Post-Intubation/Extubation
• Post-Operative
• Any Significant Changes in Patients Condition
 ASSESSMENT
ASSESSMENT
The first step in determining a patients’ health
status.
Gather information, put pieces of the health
puzzle together.
Entire plan is based on the data you collect, data
needs to be complete and accurate
Collect, verify, and organize data, identify
patterns, report and record the data.

Report significant abnormalities immediately.

 ASSESSMENT
ASSESSMENT
SUBJECTIVE DATA OBJECTIVE DATA
DESCRIPTION Data elicited and Data directly and indirectly
verified by the patient observed through
measurement

SOURCES Client, Family and Observations and physical

significant others, assessment findings of the
patient medical nurse, or other health care
record, other health professionals
care professionals

METHODS TO Client interview Observation and physical

OBTAIN DATA examination

SKILLS NEEDED Interview and Inspection, palpation,

therapeutic percussion and auscultation
communication skills
 NURSING DIAGNOSIS
NURSING DIAGNOSIS
• NURSING DIAGNOSIS is a clinical judgment
concerning human response to health
conditions/life processes, or a vulnerability for
that response, by an individual, family, group,
or community. 
• provides the basis for the selection of nursing
interventions to achieve outcomes for which
the nurse has accountability. 
• are developed based on data obtained during
the nursing assessment and enable the nurse
to develop the care plan.
 NURSING DIAGNOSIS
NURSING DIAGNOSIS
• NURSING DIAGNOSIS is a clinical judgment
concerning human response to health
conditions/life processes, or a vulnerability for
that response, by an individual, family, group,
or community. 
• provides the basis for the selection of nursing
interventions to achieve outcomes for which
the nurse has accountability. 
• are developed based on data obtained during
the nursing assessment and enable the nurse
to develop the care plan.
 DIAGNOSIS
DIAGNOSIS
client’s data base
contains risk factors
of diagnosis, but no
actual evidence of true evidence
signs/symptoms of
diagnosis exist
DIAGNOSIS
DIAGNOSIS

Ineffective Airway Clearance related to

retained mucus secretions as evidenced by
ineffective cough and production of
secretions.

Risk for infection related to alterations in

immune system
WRITING A NURSING DIAGNOSIS
WRITING A NURSING DIAGNOSIS

• Use accepted qualifying terms (Altered,

Decreased, Increased, Impaired)
• Don’t use Medical Diagnosis (Altered
Nutritional Status related to Cancer)
• Don’t state 2 separate problems in one
diagnosis
• Refer to NANDA list in a nursing text books
PLANNING
PLANNING
 INTERVENTION
INTERVENTION

•Nursing interventions are actions performed by nurse to

reach goal or outcome
•Monitor health status
•Minimize client risks
•Direct Care Intervention: Direct action performed to client
(inserting foleys catheter)
•Indirect Care Intervention: actions performed away from
client ( looking at lab results)
 DETERMINING INTERVENTIONS
DETERMINING INTERVENTIONS

• Interventions will be collaborative, combining

nursing actions and physician orders.
• Ineffective Airway Clearance related to
incisional pain
• Nursing Actions: Auscultate breath sounds
every four hours, Assist with coughing and deep
breathing every hour etc.
• Physician orders: pain medication, activity
orders
 EVALUATION
EVALUATION

• Step of the nursing process that measures the

client’s response to nursing actions and the
client’s progress toward achieving goals
• Data collected on an on-going basis
• Supports the basis of the usefulness and
effectiveness of nursing practice