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DocumentationDocumentation

Rashid HussainRashid Hussain

Nursing Instructor RMI-SONNursing Instructor RMI-SON

Objectives Objectives

Define nursing documentation (ND)Define nursing documentation (ND) Purpose of NDPurpose of ND Advantage of nursing documentationAdvantage of nursing documentation Principle of NDPrinciple of ND Example of inaccurate & accurate NDExample of inaccurate & accurate ND Different record keeping documents.Different record keeping documents. Consequences of inaccurate NDConsequences of inaccurate ND

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Nursing DocumentationNursing Documentation

Any written or electronically generated information Any written or electronically generated information about a client that describes the care or service about a client that describes the care or service provided to that client.provided to that client.

Accurate record keeping and careful Accurate record keeping and careful documentation is an essential part of nursing documentation is an essential part of nursing practice. practice.

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Nursing documentation clearly describes:Nursing documentation clearly describes: An assessment of the client’s health An assessment of the client’s health

status, nursing interventions carried out, status, nursing interventions carried out, and the impact of these interventions on and the impact of these interventions on client outcomes;client outcomes;

Information reported to a physician or Information reported to a physician or other health care provider.other health care provider.

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Purpose for documentation Purpose for documentation

To facilitate communicationTo facilitate communication To promote good nursing careTo promote good nursing care To meet professional and legal standardsTo meet professional and legal standards Satisfaction of Legal and Practice standardsSatisfaction of Legal and Practice standards EducationEducation ResearchResearch ReimbursementReimbursement

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Benefits of the Nursing NotesBenefits of the Nursing Notes

Nursing documentation provides:Nursing documentation provides:

An account of judgmentAn account of judgment Critical thinking used in the Critical thinking used in the nursingnursing

process.process.

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Cont…Cont…

Accurate, timely documentation reflects care Accurate, timely documentation reflects care provided:provided:

Professional, legislative, & agency Professional, legislative, & agency standardsstandards

Enhance nursing careEnhance nursing care Facilitate communication b/w nurses & Facilitate communication b/w nurses &

other health care providers.other health care providers.

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Cont…Cont…

It also reflects the application of :It also reflects the application of : Nursing knowledgeNursing knowledge Nursing skills & judgmentNursing skills & judgment Established accountabilityEstablished accountability Conveys the unique contribution of the Conveys the unique contribution of the

nursing to health carenursing to health care

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PRINCIPLES OF EFFECTIVEPRINCIPLES OF EFFECTIVEDOCUMENTATIONDOCUMENTATION

Use of Common VocabularyUse of Common Vocabulary Use of common vocabulary improve intra-Use of common vocabulary improve intra-

team communication and lessen the chance team communication and lessen the chance of misunderstandings.of misunderstandings.

LegibilityLegibility Writings must be easily readable, without any Writings must be easily readable, without any

chance of error.chance of error. Abbreviations and SymbolsAbbreviations and Symbols

Use only authorized abbreviations and Use only authorized abbreviations and symbols.symbols.

PRINCIPLES OF EFFECTIVEPRINCIPLES OF EFFECTIVEDOCUMENTATIONDOCUMENTATION

OrganizationOrganization Start every entry step by step with the date Start every entry step by step with the date

and time. Chart in a chronological orderand time. Chart in a chronological order AccuracyAccuracy

Use factual, descriptive terms to chart exactly Use factual, descriptive terms to chart exactly what was observed or done. Use correct what was observed or done. Use correct spelling and grammar, and write complete spelling and grammar, and write complete sentences.sentences.

PRINCIPLES OF EFFECTIVEPRINCIPLES OF EFFECTIVEDOCUMENTATIONDOCUMENTATION

Documenting a an ErrorDocumenting a an Error Facilities require nurses to report errors on Facilities require nurses to report errors on

incident reports, Document the error in the incident reports, Document the error in the nurses’ notesnurses’ notes

ConfidentialityConfidentiality Nurses are bound by ethical codes and laws Nurses are bound by ethical codes and laws

to treat all client information in a confidential to treat all client information in a confidential and professional manner. The client records and professional manner. The client records should not be with unconcerned personnelshould not be with unconcerned personnel

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Guidelines For DocumentationGuidelines For Documentation

FactualFactual AccurateAccurate CompleteComplete CurrentCurrent OrganizedOrganized

How to writ nurses’ notesHow to writ nurses’ notes

A = AirwayA = Airway B = BreathingB = Breathing C = CirculationC = Circulation D = DrainageD = Drainage E = EliminationsE = Eliminations F = FluidsF = Fluids G = GCSG = GCS

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Inaccurate ExampleInaccurate Example

Mr. X received from morning staff in well Mr. X received from morning staff in well condition. Well oriented, eating well. condition. Well oriented, eating well. Vital signs checked & recorded. Vital signs checked & recorded. Physician checked the pt, no any further Physician checked the pt, no any further order. Continue same RX.order. Continue same RX.

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Accurate ExampleAccurate Example

Mr. X. received from Night shift. Oriented Mr. X. received from Night shift. Oriented to time, place & person. Breathing to time, place & person. Breathing spontaneously on room air, RR=20/m. spontaneously on room air, RR=20/m. B.P 110/ 70mmgh, pulse=80/m. chest B.P 110/ 70mmgh, pulse=80/m. chest tube in placed with bubbling & column tube in placed with bubbling & column movement present. catheter in placed movement present. catheter in placed urine output 30ml/hr, stool passed urine output 30ml/hr, stool passed normally. IV fluids 100ml / hr continue normally. IV fluids 100ml / hr continue for 24 hrs.________ A.Razzak.for 24 hrs.________ A.Razzak.

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Record Keeping FormsRecord Keeping Forms

Nursing history (HX)Nursing history (HX) Graphic or flow sheetGraphic or flow sheet Medication administration recordMedication administration record Nursing KARDEXNursing KARDEX Standardized care plansStandardized care plans Discharge summaryDischarge summary

Methods of DocumentationMethods of Documentation

Narrative ChartingNarrative Charting Source-oriented Source-oriented

chartingcharting Problem-oriented Problem-oriented

chartingcharting PIE chartingPIE charting

Focus chartingFocus charting Charting by Charting by

exceptionexception Computerized Computerized

documentationdocumentation Critical pathwaysCritical pathways

Narrative ChartingNarrative Charting

This traditional method of nursing This traditional method of nursing documentation takes the form of a story documentation takes the form of a story written in paragraphs.written in paragraphs.

Before the advent of flow sheets, this Before the advent of flow sheets, this was the only method for documenting was the only method for documenting care.care.

Source-Oriented ChartingSource-Oriented Charting

A narrative recording by each member A narrative recording by each member (source) of the health care team on (source) of the health care team on separate records.separate records.

Problem-Oriented ChartingProblem-Oriented Charting

Focuses on the client’s problem and Focuses on the client’s problem and employs a structured, logical format employs a structured, logical format called SOAPIE charting:called SOAPIE charting:

S: Subjective data (what the client states)S: Subjective data (what the client states) O: Objective data (what is observed/inspected)O: Objective data (what is observed/inspected) A: AssessmentA: Assessment P: PlansP: Plans I: InterventionI: Intervention E: EvaluationE: Evaluation

PIE ChartingPIE Charting

PROBLEMPROBLEMINTERVENTIONINTERVENTIONEVALUATIONEVALUATION

Focus ChartingFocus Charting

A documentation method that uses a A documentation method that uses a column format to chart data, action, and column format to chart data, action, and response (DAR). response (DAR).

Charting by ExceptionCharting by Exception

A documentation method that requires A documentation method that requires the nurse to document only deviations the nurse to document only deviations from pre-established norms.from pre-established norms.

Computerized Documentation:Computerized Documentation:AdvantagesAdvantages

Decreased Decreased documentation time.documentation time.

Increased legibility and Increased legibility and accuracy.accuracy.

Clear, decisive, and Clear, decisive, and concise words.concise words.

Statistical analysis of Statistical analysis of data.data.

Enhanced Enhanced implementation of the implementation of the nursing process.nursing process.

Enhanced decision Enhanced decision making.making.

Multidisciplinary Multidisciplinary networking.networking.

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Consequences Of Consequences Of Inadequate DocumentationInadequate Documentation

Fragmented careFragmented care Repetition of tasksRepetition of tasks Delayed therapyDelayed therapy Omitted therapyOmitted therapy Delayed recoveryDelayed recovery

RefrencesRefrences

DUGas, B., Esson, L. & Ronaldson, S.DUGas, B., Esson, L. & Ronaldson, S.(1999). (1999). Nursing Foundation: A Canadian Nursing Foundation: A Canadian

Perspective. Perspective. Scarborough: Prentice Hall Scarborough: Prentice Hall Canada, P. 480Canada, P. 480

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