TITTLE

DOCUMENTATI
ON
 OBJECTIVES
• Determine the definition of documentation.
• To know purposes of documentation.
• To know the tools and documentation
methods.
• To know documentation using technology
system.
• To discuss the intake and output chart (I&O).
 NURSING PROCESS

1.Assessment

5.Evaluation

2.Nursing Diagnosis

4.Implementation 3.Planning

Documentati
on
 DEFINITION
• Documentation is any written or electronically
generated information about a client that
describes the care or service provided to that
client. Health records may be paper documents
or electronic documents, such as electronic
medical records, faxes, e-mails, audio or video
tapes and images.
• Through documentation, nurses communicate
their observations, decisions, actions and
outcomes of these actions for clients.
• Documentation is an accurate account of what
occurred and when it occurred.
• Nurses may document information pertaining to
individual clients or groups of clients.
 Purpose of the Nursing
Documentation
• Communication
• Among the professionals of the health system, through
the exchange of information that concerns the patient.
• Creation of the Patient Care Plan
• Each scientist uses documents from the patient’s file
to prepare the care plan of the particular patient.
• Control of the health organizations.
• The control is a review of the patient’s file with the
view to confirm the provided quality.
• Research
• The information, that is contained in a file can form a
valuable source of elements for research. The care
plan can bring up useful information on the care of
many patients.
 Purpose of the Nursing
Documentation (cont.)
• Education
• Students in various schools of the health science often use
patients’ files as educational tools.
• Compensation
• The documentation also assists in obtaining easily a
compensation from the public and private insurances. In
order to obtain a compensation, the file of the patient’s
clinical situation should have the right diagnosis, which
should be included in the group of illnesses that are being
compensated and also report that the appropriate care has
been provided.
• Legal documentation
• The patient’s file is a legal document and is often
acceptable at the court as an evidence.
• Analysis of the Health Care
» The information of the files can assist the professionals of the health
system to point out the needs of the particular nursing institution, as
well as the hospital’s services.
• Funding and resource management
 A nurse maintains
documentation that is:
• clear, concise and comprehensive
• accurate, true and honest; relevant
• reflective of observations, not unfounded conclusions
• timely and completed only during or after giving care;
chronological;
• a complete record of nursing care provided including
assessments, identification of health issues, a plan of
care, implementation, and evaluation;
• legible and non-erasable;
• permanent; retrievable; confidential; client-focused
 Documentation Methods
• FOCUSCHARTING
• With this method of documentation, the nurse identifies a
“focus” based on client concerns or behaviours determined
during the assessment. For example, a focus could reflect:
• A current client concern or behaviour, such as decreased
urinary output.
• A change in a client’s condition or behavior, such as
disorientation to time, place and person.
• A significant event in the client’s treatment, such as return
from surgery.
• In focus charting, the assessment of client status, the
interventions carried out and the impact of the
interventions on client outcomes are organized under the
headings of data, action and response.
• Data: Subjective and/or objective information that supports
the stated focus or describes the client status at the time of
a significant event or intervention.
• Action: Completed or planned nursing interventions based
on the nurse’s assessment of the client’s status.
• Response: Description of the impact of the interventions on
client outcomes.
 Documentation Methods
•
(cont.)
SOAP/SOAPIE(R)CHARTING
• SOAP/SOAPIER charting is a problem-oriented approach to
documentation whereby the nurse identifies and lists client
problems; documentation then follows according to the
identified problems.
• Documentation is generally organized according to the
following headings:
– S = subjective data (e.g., how does the client feel?)
– O = objective data (e.g., results of the physical exam, relevant vital
signs)
– A = assessment (e.g., what is the client’s status?)
– P = plan (e.g., does the plan stay the same? is a change needed?)
– I = intervention (e.g., what occurred? what did the nurse do?)
– E = evaluation (e.g., what is the client outcome following the
intervention?)
– R = revision (e.g., what changes are needed to the care plan?)
• Similar to focus charting, flow sheets and checklists are
frequently used as an adjunct to document routine and ongoing
assessments and observations.
Documentation Methods
(cont.)
• NARRATIVECHARTING
• Narrative charting is a method in which
nursing interventions and the impact of
these interventions on client outcomes are
recorded in chronological order covering a
specific time frame. Data is recorded in the
progress notes, often without an organizing
framework. Narrative charting may stand
alone or it may be complemented by other
tools, such as flow sheets and checklists.
 Documenting Nursing
Activities
• Worksheets and Kardexes
• Widely used, concise method of organizing and
record data about client, making information
quickly accessible to all health professional.
• May or not become client’s permenant record.
• Example information in Kardexes:
– Pertinent info. About the client ( name, room no., age,
admission date, physician’s name and type surgery)
– Allergies
– List medication and time administration
– List of daily treatment and procedure
– A problem list and list nursing goal
 Documenting Nursing
Activities (cont.)
• Client care plans
– Two type:
• Traditional care plan
– Written for each patient
– The form varies from agency to agency according
to the needs of the clients and department
• standardizedcare plan
– To save documentation time
– Based on an institution's standards of practice
– Helping to provide a high of nursing care
 Documenting Nursing
Activities (cont.)
• Flow sheets and checklists
• To record nursing data quickly and concisely and provides
and easy-to- read of the clien condition over time
• Example:
a)Graphic record
• Eg. : body temperature, pulse, respiration rate, blood pressure,
significant clinical data ( admission and postoperative day,
bowel movement, appetite and activity)
a)Intake and Output record
• Measure output and intake daily
a)Medication administration record
• Eg: medication order, frequency, expired date, route, and
nurse signature.
a)Skin assessment record
• Eg: stage of skin injury, darinage, odor, culture information,
and treatment.
 Documenting Nursing
Activities (cont.)
• Progress note
• Made by nurses provide information about
the progress a clients is making toward
achieving desired outcomes.
• Include: asessment, reassessment data,
client problems and nursing intervention.
• Care maps and clinical pathways
• Monitoring strips
 Documentation for Nursing
Process
Step Documentation Form
Assessment Initial assessment form, various
flow sheets

Nursing diagnosis Nursing care plan, critical

parthway, progress note, problem
list
Planning Nursing care plan, critical pathway

Implementing Progress note, flow sheet

Evaluating Progress note

 Use of Technology In
Nursing Documentation
a) Electronic documentation
• Must be comprehensive, accurate, timely, and clearly
identify who provided what care.
a) Fax Transmission
• A convenient and efficient method for communicating
information between health care providers
a) Electronic Mail
• Becoming more widespread as a result of its speed,
reliability, convenience and low cost.
• Unfortunately the factors that make the use of e-mail so
advantageous also pose significant confidentiality,
security and legal risks.
a) Telenursing.
• Nurses who provide telephone care are required to
document the telephone interaction.
• Documentation may occur in a written form (e.g., log
book or client record form) or via computer
 Long-Term Care
•
Documentation
Nurse need to familiarize themselves with the
regulation influencing the kind and frequency of
documentation required in long-term care facilities.
Nursing care summary complete at least once a week
for clients requiring skilled care and every two week
fo those requiring intermediate care.
• Summaries should address as following:
• Specific problems noted in the care plan.
• Mental status.
• Activities of daily living
• Hydration and nutrition status.
• Safety measures needed.
• Medications.
• Treatments.
• Preventive measures.
• Behavior modification assessment, if patients taking
psychotropic medication or demonstrates behavior problems.
INTAKE AND
OUTPUT
CHART
 Measuring and Record
Intake/Output
• Physicians orders intake and output
• Intake include:
• All liquid taken by mouth
• Food items that turn to liquid at room
temperature
• Tube feeding into stomach trough nose and
abdomen
• Fluids given by intravenous infusion
 Measuring and Record
Intake/Output 9cont.)
• Output includes:
• Urine
• Liquid stool
• Emesis
• Drainage
• Suctioned secretions
• Excessive perspiration
 PROCEDURE MEASURING
INTAKE AND OUTPUT
1. Assess the client’s risk factors for fluid overload such
as congestive heart failure, renal failure, or ascites.
2. Determine if the client is receiving fluids or medication
that would predispose him to fluid overload such as
large amounts of IV fluids or steroid therapy.
3. Assess the client’s risk factors for fluid loss such as
diaphoresis, rapid respirations, diarrhea, gastric
suction, blood loss, pr wound drainage.
4. Determine if the client’s urine output is in excess of his
fluid intake, because the kidneys excrete excess fluid
during periods of over hydration and conserve body
water during periods of dehydration.
5. Wash hands.
6. Explain the rules of I&O record. All fluids taken orally
must be recorded on the client’s intake and output
form ( sometimes called a fluid balance flow sheet)
 PROCEDURE MEASURING
INTAKE AND OUTPUT
7.
(Cont.)
Measure all oral fluids in accord with agency policy: eg.
=150ml,glss=240ml. Record all IV fluid as they are infused.
a) Client must avoid into bedpan or urinal, not into the toilet
b) Toilet tissue should be disposed of in plastic-lined container, not in bedpan.
8. Record the time and amount of all fluid intake the designated
space on the bedside form (oral, tube feeding, IV fluids). Record
measurements immediately instead of waiting until the end of
the shift.
9. Transfer the 8 hour total fluid intake from the bedside I&O
record to graphic sheet or 24 h I&O on the client’s chart.
10. Record all forms of intake, except blood and blood products in
the appropriate column of the 24h record.
11. Complete the 24h intake record by adding all 8 h total.
12. Output-Apply nonstrile glove
 PROCEDURE MEASURING
INTAKE AND OUTPUT
(Cont.)
13. Empty the urinal, bedpan,or foley drainage bag into a
graduated container or commode ‘hat’.
14. Remove the glove and wash hand.
15. Record the time and amount of output on the bedside
I&O record. Record measurement immediately instead of
waiting until the end of shift.
16. Transfer 6h output totals to graphic sheet or 24 h I&O
record on the client’s chart.
17. Complete the 24 h output record by totaling all the 8 h
totals. Do not have visitors or family members empty
bedpans, urinals or catheter bags.
18. Wash hands.
19. Document measured intake and output at patient’s chart.
• Total score
• Date clinical instructor signature
 Common errors in
measuring fluid intake
and output
• Errors in recording
• Failure to communicate to the entire staff which
patients are on fluid balance charts
• Failure to explain input/output principles to
patient and/or relatives
• Well meaning intentions to record volumes at a
more  convenient time, leading to omissions
• Failure to measure volumes when it is quicker
to guess
 Common errors in
measuring fluid intake
and output
• Errors related to intake
(cont.)
• Failure to designate the specific volume of containers e.g.
glasses, cups.
• Failure to obtain adequate measuring devices for small
amount of oral fluids.
• Failure to consider volumes of fluid displaced by ice,
leading to over estimation.
• Over estimation of fluid volume contained in ice cubes.
• Failure to consider that parenteral bottles are over-filled.
• Assumption that the contents of empty containers have
been taken by the patient.
 Common errors in
measuring fluid intake
and output (cont.)
• Errors related to output
• Failure to estimate fluid lost as perspiration.
• Failure to estimate fluid lost in uncaught vomitus.
• Failure to estimate fluid lost in episodes of incontinence.
• Failure to estimate fluid lost in liquid faeces.
• Failure to estimate fluid lost as wound exudate.
• Failure to check patency of urinary catheters when output
decreasing.
• Failure to account for fluid volume used to prime tubes etc.
• Failure to account for fluid volume lost during dialysis