DOCUMENTATION

4-Documenting and Reporting

First Stage
M.SC.N. Moustafa Ali Alshammari | ALtoosi
college university – Iraq
Fundamentals of Nursing I
 Documentation as
Communication
• Documentation
– Written evidence of:
• Interactions
• Administration of tests, therapies, and education
• Client’s responses

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 Purposes of Health Care
Documentation
• Communication
• Education
• Research
• Reimbursement

(continued)
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 Purposes of Health Care
Documentation
• Legal and practice standards
– Informed consent

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 Elements of Effective
Documentation
• Legibility
• Abbreviations and symbols
• Organization
• Accuracy
• Documenting medication error
• Confidentiality

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 Methods of Documentation
• Narrative charting
• Source-oriented charting
• Problem-oriented charting
• Focus charting

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 Example of Organizing Narrative Charting

1000 Diminished breath sounds in all lung fields with

crackles in LLL. Not using incentive spirometer (IS). Stated
he’s “not sure how to use it.” Temperature 99.6. Instructed
how to use IS. Discussed the importance of deep breathing and
coughing after surgery. Administered analgesic for
c/o abdominal pain rating of 5/10. After pain relief (1/10),
able to demonstrate correct use of IS. ––––– S. Martin, RN
1400 Using IS each hour. Lungs less diminished with fewer
LLL crackles. Temp 99. ––––––––––––––––– S. Martin, RN

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 Example of progress notes (DAR)

Date/Hour Focus Progress Notes

2/11/15 Pain D: Guarding abdominal incision.
0900 Facial grimacing.
Rates pain at “8” on scale
of 0–10
A: Administered morphine
sulfate 4 mg IV.
0930 R: Rates pain at “1.” States
willing to ambulate.

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 Forms for Recording Data
• Flow sheet
• Nurse’s progress notes

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 Reporting
• Summary reports
• Telephone reports and orders
• Incident reports

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 Computers in Nursing
• Professional nurse as information consumer and
producer
• Informatics competencies for nurses
• Applications of nursing informatics
• Telehealth

(continued)
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 Computers in Nursing
• Evidence-based practice and research
• Criteria for evaluating validity of information

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 SOAP

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 Commonly Used Abbreviations

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Thank you

You can find me at:

mustafa11ali@yahoo.com