By the end of this lecture the student will be able

to :

Define nursing documentation

Describe the content of nursing documentation

and record formats

List purpose of nursing documentation

Explain elements of effective documentation

List forms for recording data and benefits of

electronic documentation system

Documentation with in a clients medical

record is a vital aspect of nursing care

The nursing documentation must be

accurate comprehensive and flexible

Is the record of the nursing care that is

planned and delivered to individual clients

by qualified nurses or other caregiver under

the direction of qualified nurse

Nursing documentation is principal clinical

information source to meet legal and

professional requirements and one of the

most significant components in nursing care

The nursing documentation consists of the

following :

1. Admission form is fundamental record in

nursing documentation it documents a

clients status& reasons for admitted and it

provides the basic information

2. Assessment is the recording of the process

about how a judgment was made and it

related factors

3. Nursing care plan is clinical document

recording the nursing process which is

systematic method of planning and

providing care to the clients

4. Progress notes is the record of the nursing

action and observation in nursing care

process

1. Paper based nursing documentation :

It has been in place for decades , clients

data are recorded in paper documents

2. Electronic nursing documentation :

Is an electronic nurses format of nursing

documentation

1. A guide for reimbursement of care costs .

2. Evidence of care in a court of law .

3. Show the use of nursing process .

4. Provide data for quality assurance studies .

5. Show progress toward expected outcome .

Nurses are responsible for assessing and

documenting that the client has an

understanding of treatment prior to

intervention.

Two indicators of the above are :

Informed Consent

Advance Directives

A competent client’s ability to make

health care decisions based on full

disclosure of the benefits, risks, and

potential consequences of a

recommended treatment plan.

The client’s agreement to the treatment

as indicated by the client’s signing a

consent form.

Written instructions about a client’s

health care preferences regarding life-

sustaining measures.

Allows clients, while competent, to

participate in end-of-life decisions.

Use a common vocabulary.

Write legibly and neatly.

Use only authorized abbreviations and symbols.

Employ factual and

time-sequenced

organization.

Document

accurately and

completely,

including any

errors.

To ensure effective documentation, nurses should:

1. Kardex

2. Flow sheet

3. Nursing progress

note

4. Discharge summary

A summary worksheet reference of basic information that traditionally is not part of the record. Usually contains: Client data (name, age, marital status ,

religious ,preference, physician, family contact).

Medical diagnoses: listed by priority. Allergies. Medical orders (diet, IV therapy, etc.). Activities permitted.

Vertical or horizontal columns for recording dates and times and related assessment and intervention information. Also included are notes on:

Client teaching.

Use of special equipment.

IV Therapy.

Used to document:

Client’s condition, problems, and complaints.

Interventions.

Client’s response to interventions.

Achievement of outcomes.

Highlights client’s illness and course of care. Includes: Client’s status at admission and discharge. Brief summary of client’s care. Intervention and education outcomes. Resolved problems and continuing care

needs. Client instructions regarding medications,

diet, food-drug interactions, activity, treatments, follow-up and other special needs.

The outlining of information pertinent to the client’s needs as identified by the nursing process.

Commonly given at end-of-shift.

A reporting method used when the members of the care team walk to each client’s room and discuss care and progress with each other and with the client.

Telephone communications are another way nurses:

Report transfers.

Communicate referrals.

Obtain client data.

Solve problems.

Inform a client’s family members regarding a change in client’s condition.

The documentation of any unusual occurrence or accident in the delivery of client care, such as falls or medication errors.

1. Improvement of comprehensiveness in

documenting the nursing process

2. The use of standardized language and the

recording of specific items about particular

client issue and relevance of the massage

3. Improve legibility dating and signing in

nursing record

4. Due to automatic function were able to

improve format and structure and process

feature of documentation quality

5. Save the time and prevent duplication or

error in the patient care

6. Accurate and effective documentation

ensures continuity of care

•We must become the change we want to see. -(Mahatma Gandhi)

..تعالوا نكون مثلا للتغيير الذي نود أن نراه •

)مهاتما غاندي(

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