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Documentation

Rashid Hussain Nursing Instructor RMI-SON

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ACN

Objectives
Define

nursing documentation (ND) Purpose of ND Advantage of nursing documentation Principle of ND Example of inaccurate & accurate ND Different record keeping documents. Consequences of inaccurate ND
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Nursing Documentation
Any written or electronically generated information about a client that describes the care or service provided to that client.

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

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Nursing documentation clearly describes: An assessment of the clients health status, nursing interventions carried out, and the impact of these interventions on client outcomes; Information reported to a physician or other health care provider.

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Purpose for documentation

To facilitate communication To promote good nursing care To meet professional and legal standards Satisfaction of Legal and Practice standards Education Research Reimbursement

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Benefits of the Nursing Notes


Nursing documentation provides:
An

account of judgment Critical thinking used in the nursing process.

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Accurate, timely documentation reflects care provided: Professional, legislative, & agency standards Enhance nursing care Facilitate communication b/w nurses & other health care providers.

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It also reflects the application of : Nursing knowledge Nursing skills & judgment Established accountability Conveys the unique contribution of the nursing to health care

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PRINCIPLES OF EFFECTIVE DOCUMENTATION

Use of Common Vocabulary Use of common vocabulary improve intrateam communication and lessen the chance of misunderstandings. Legibility Writings must be easily readable, without any chance of error. Abbreviations and Symbols Use only authorized abbreviations and symbols.

PRINCIPLES OF EFFECTIVE DOCUMENTATION

Organization Start every entry step by step with the date and time. Chart in a chronological order Accuracy Use factual, descriptive terms to chart exactly what was observed or done. Use correct spelling and grammar, and write complete sentences.

PRINCIPLES OF EFFECTIVE DOCUMENTATION

Documenting a an Error Facilities require nurses to report errors on incident reports, Document the error in the nurses notes Confidentiality Nurses are bound by ethical codes and laws to treat all client information in a confidential and professional manner. The client records should not be with unconcerned personnel

Guidelines For Documentation


Factual
Accurate Complete Current Organized

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How to writ nurses notes


A

= Airway B = Breathing C = Circulation D = Drainage E = Eliminations F = Fluids G = GCS


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

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


Nursing

history (HX) Graphic or flow sheet Medication administration record Nursing KARDEX Standardized care plans Discharge summary

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Methods of Documentation

Narrative

Charting Source-oriented charting Problem-oriented charting PIE charting

Focus

charting Charting by exception Computerized documentation Critical pathways

Narrative Charting

This traditional method of

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

Before the advent of flow sheets, this


was the only method for documenting care.

Source-Oriented Charting

A narrative recording by each member


(source) of the health care team on separate records.

Problem-Oriented Charting

Focuses on the clients problem and



employs a structured, logical format called SOAPIE charting:
S: Subjective data (what the client states) O: Objective data (what is observed/inspected) A: Assessment P: Plans I: Intervention E: Evaluation

PIE Charting

PROBLEM INTERVENTION EVALUATION

Focus Charting

A documentation method that uses a


column format to chart data, action, and response (DAR).

Charting by Exception

A documentation method that requires


the nurse to document only deviations from pre-established norms.

Computerized Documentation: Advantages

Decreased documentation time. Increased legibility and accuracy. Clear, decisive, and concise words.

Statistical analysis of data. Enhanced implementation of the nursing process. Enhanced decision making. Multidisciplinary networking.

Consequences Of Inadequate Documentation


Fragmented

care Repetition of tasks Delayed therapy Omitted therapy Delayed recovery

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Refrences
DUGas,

B., Esson, L. & Ronaldson, S.

(1999). Nursing Foundation: A Canadian Perspective. Scarborough: Prentice Hall Canada, P. 480

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