DOCUMENTATION

Presented to: Madam Mrs. Avinash Rana Presented to: Mukta (m.sc.1st yr)

INTRODUCTION

Equally important as using the nursing process in the delivery of care is the written documentation that it has been used. Some contemporary nursing leaders are advocating that with solid standards of practice & procedures in place within the institution, nurses need only chart when there has been a deviation in the care as outlines by the standards.

CONTD..

However many legal decisions are still based on the precept that if It was not charted, it was not done. Because nursing process & nursing diagnosis are mandated by nursing practice acts in some states, documentation of their use is being considered in those states as evidence in determining certain cases of negligence by nurses.

CONTD..

Some health care organizations accrediting agencies also require that nursing process be reflected in the delivery of care. Therefore, documentation must bear written testament to the use of the nursing process. Many methods have been used to reflect use of nursing process in delivery of nursing care. Example: problem oriented recording, focus charting & PIE method.

METHODS OF DOCUMENTATION

1. PROBLEM-ORIENTED RECORDING

It follows the subjective, objective , assessment, plan, implementation, and evaluation (SOAPIE) format.
It has its basis a list of problems. When it is used in nursing, the problems or nursing diagnosis are identified on a written plan of care with appropriate nursing interventions decided for each.

SOAPIE Format steps

S = subjective data: information gathered

from what the client, family, or other source has said or reported.

O = objective data: information gathered by

direct observation of the person performing the assessment; may include a physiological measurement such as blood pressure or a behavioral response such as affect.

STEPS CONTD..

A = assessment; the nurses interpretation of

the subjective and objective data.

P = plan; the actions or treatments to be

carried out ( may be omitted in daily charting if the plan is clearly explained in the written nursing care plan and no changes are expected).

I = intervention: those nursing actions that

were actually carried out.

STEPS CONTD..

E = evaluation of the problem following nursing intervention ( some nursing interventions can not be evaluated immediately, so this section may be optional ).
It can be conclude that POR corresponds to the steps of the nursing process.

SOAI FORMAT

DATE/TIME PROBLEM
5-11-2008 Social isolation

PROGRESS NOTES
S : states he does not want to sit or talk to others. They frighten him, stays in room alone unless encouraged to come out, no group involvement, at times listens to group conversations from a distance, but does not interact. O : social isolation related to inability to trust, panic level of anxiety, and delusional thinking.

DATE/TIME PROBLEM 5-11-2008

PROGRESS NOTES
A : initiated trusting relationships by spending time alone with the client; discussed his feelings regarding interactions with others; accompanied client to group activities; provided positive feedback for voluntarily participating in assertive training. I : cooperative with the therapy; still acts uncomfortable in the presence of a group of people; accepted positive feedback from the nurse.

2. FOCUS CHARTING

Another type of documentation that reflects use of the nursing process is focus charting.
Focus charting differs from POR in that the main perspective has been changed from problem to focus and data, action, and response (DAR), has replaced SOAPIE. The focus cannot be a medical diagnosis. The documentation is organized in the format of DAR.

CONTD..

Lampe (1985) suggests that a focus for documentation can be any of the following:-

1. 2. 3. 4.

Nursing diagnosis Current client concern or behavior Significant change in the client status or behavior Significant event in the clients therapy.

STEPS OF FOCUS CHARTING

D = data; information that supports the stated

focus or describes pertinent observations about the client. A = action; immediate or future nursing actions that address the focus, and evaluation of the present care plan along with any changes required. R = response; description of the clients response to any part of the medical or nursing care.

DAR FORMAT

DATE/TIME PROBLEM PROGRESS NOTES 5-11-2008 social D : states he does not isolation want to sit or talk to related to others. They frighten inability to him, stays in room trust, panic alone unless level of encouraged to come anxiety, out, no group and involvement, at times delusional listens to group thinking. conversations from a distance, but does not interact.

DATE/TIME PROBLEM 5-11-2008

PROGRESS NOTES
A : initiated trusting relationships by spending time alone with the client; discussed his feelings regarding interactions with others; accompanied client to group activities; provided positive feedback for voluntarily participating in assertive training. R : cooperative with the therapy; still acts uncomfortable in the presence of a group of people; accepted positive feedback from the nurse.

THE PIE METHOD

PIE, or more specially APIE (assessment, problem, intervention, evaluation), is a systemic method of documenting to nursing process and nursing diagnosis.
A problem - oriented system, PIE charting uses accompanying flow sheets that are individualized by each institution.

CRITERIA FOR DOCUMENTATION IN PIE METHOD

A = assessment; a complete client assessment

is conducted at the beginning of each shift. Results are documented under this section in progress noted. Some institutions elect instead to use a daily client assessment sheet designed to meet specific needs of the unit. Explanation of any deviation from the progress norm is included in the progress notes.

CONTD..

P = problem; a problem list or list of nursing

diagnoses, is an important part of APIE method of charting. The name or number of the problem being addressed is documented in this section.

I = intervention; nursing actions are

performed, directed at resolution of the problem.

CONTD..

E = evaluation; outcomes of the implemented

interventions are documented, including an evaluation of client responses to determine the effectiveness of nursing interventions and the presence or absence of progress toward resolution of a problem.

APIE charting corresponds to the steps of the nursing process.

APIE FORMAT

DATE/TIME PROBLEM
5-11-2008 Social isolation

PROGRESS NOTES
A : states he does not want to sit or talk to others. They frighten him, stays in room alone unless encouraged to come out, no group involvement, at times listens to group conversations from a distance, but does not interact. P : social isolation related to inability to trust, panic level of anxiety, and delusional thinking.

DATE/TIME PROBLEM 5-11-2008 Social isolation

PROGRESS NOTES
I : initiated trusting relationships by spending time alone with the client; discussed his feelings regarding interactions with others; accompanied client to group activities; provided positive feedback for voluntarily participating in assertive training. R : cooperative with the therapy; still acts uncomfortable in the presence of a group of people; accepted positive feedback from the nurse.

IMPORTANCE IN PSYCHIATRIC NURSING

The psychiatric nurse uses the nursing process to assist clients to adapt successfully to stressors within the environment. Goals are directed toward change in thoughts, feelings, & behaviors that are age appropriate and congruent with local & cultural norms. Nursing in psychiatry is goal directed. Role of case management is being expanded, and used in planning.

CONTD..

The nurse is an important member of the interdisciplinary treatment team, working both independently & cooperatively with other team members.
Nursing diagnosis, in its ability to define the scope of nursing practice, is facilitating nursing role in the psychiatric setting by differentiating that which is specifically nursing from interventions associated with other disciplines.

SUMMARY

The nursing process provides a methodology by which nurses may deliver care using a systematic, scientific approach. Nursing process is inherent within the nursing process. The concept of nursing diagnosis is not new, but became formalized only with the organization of NANDA in the 1970s. Nursing process defines the scope and boundaries for nursing.

CONTD..

1. 2. 3. 4. 5. 6.

The focus is goal directed and based on a decision-making or problem-solving model, consisting of 6 steps: Assessment Diagnosis Outcome identification Planning Implementation And evaluation

REFERENCES :

Gerard j. tortora ; Bryan derrickson, principles of anatomy and physiology, 11th edition, john Wiley & sons, inc publication. www.googles.co.in Merry C. Townsend, psychiatry mental health nursing, 5th edition, jaypee publications.

THANK YOU