NURSING

DOCUMENTATION
and

NURSING
PROCESS

PREPARED BY:

REMINA G.
AYSON R.N.

WHAT
IS

NURSI
NG?

NURSING
> the diagnosis of human responses to
actual and potential problems.
-- American Nurses Association
> the act of utilizing the environment
of the patient to assist him in his
recovery.
-- Florence Nightingale
> to assist the individual sick or well.
-- Virginia Henderson

Common Themes:
Nursing is Caring.
Nursing is an Art.
Nursing is Science.
Nursing is Client-Centered.
Nursing is Holistic.
Nursing is Adaptive.
Nursing is concerned with
health Promotion, Health
Maintenance and Health
Restoration.
Nursing is a Helping
Profession.

DOCUMENTATION

DOCUMENTATION
- is anything written or
printed that is relied on
as record or proof for
authorized person.

Why is there a need for

nursing documentation?
Record keeping is an integral
part of nursing and midwifery
practice. It is a tool of
professional practice and one
that should help the care
process. It is not separate
from this process and it is not
an optional extra to be fitted
in if circumstances allow.
(Nursing & Midwifery Council
April 2002)

Good record keeping

promotes:
High standards
of clinical care
Continuity of
care
Better
communication &
dissemination of
information

What is expected of a registered

nurse?
The quality of your record
keeping is a reflection of the
standard of your professional
practice.
Good record keeping is a mark of
a skilled and safe practitioner.

Record keeping
A full account of your assessment
should
and
the care you have planned
and provided
demonstrate:
Relevant
information about the
condition of the patient at any
given time and the measures you
have taken to respond to their
needs
Evidence that you have
understood and honoured your
duty of care
That you have taken all
reasonable steps to care for the
patient and any action or

Different Sheets:
1. Nursing Health History and Assessment Worksheet
- completed upon admission.
> Biographic data
> Age, sex and address
> Method of admission
2. Graphic Flowsheet
- it allows the nurse to record specific measurements
on a repeated basis.
> Vital signs
> Intake and Output
3. Medicine & Treatment record
- allows for the repeated recording of medication and
treatment of the patient on a repeated basis.

4. Nursing Kardex
R Readily accessible.
E Ensure continuity of care.
S Series of flips cards kept at a portable index
file at the nurses station.
T Tool for communication.
2 Parts:
1. Activity and Treatment Section
2. Nursing Care Plan

5. Discharge Summary
- helps ensure that the clients condition during
discharge is in desirable outcome.
F Final physical assessment.
I Instructions about medications and treatment regimen.
R Record pertinent data.
A Assess the client support system.
H Health teaching.

Guidelines of Quality
Documentation and
Reporting:
1. Factual
> A record must contain descriptive, objective
information about what a nurses sees, hears,
feels and smells.
The use of vague terms such as appears,
seems and apparently, is not acceptable
because these words suggest that the nurse
is stating an opinion.
2. Accurate
> The use of exact measurements establish
accuracy .
> Documentation of concise data is clear and
easy to understand.
> It is essential to avoid the use of
unnecessary words and irrelevant details.

3. Complete
> The information within a recorded entry
or a report needs to be complete,
containing appropriate and essential
information.
4. Current
> Timely entries are essential in the
clients ongoing care. To increase
accuracy and decrease unnecessary
duplication, many healthcare agencies
use records kept near the clients bedside
which facilitate immediate documentation
of information as it is collected from a
client.
5. Organized
> The nurse communicates information
in a logical order.

Legal Guidelines for Recording:

Draw single line through error,
write word error above it and sign
your name or initials. Then record
note correctly.
Do not write retaliatory or critical
comments about the client care by
other health care professionals.

Enter only objective descriptions of clients behavior;

clients comments should be quoted.
Correct all errors promptly.
Errors in recording can lead to errors in treatment.
Avoid rushing to complete charting, be sure
information is accurate.
Do not leave blank spaces in nurses notes.
Chart consecutively, line by line; if space is left, draw

 Record all entries legibly and in blank ink.

Never use pencil, felt pen.
Black ink is more legible when records are
photocopied or transferred to microfilm.
If order is questioned, record that clarification
was sought.
If you perform orders known to be incorrect, you are
just as liable for prosecution as the physician is.
Chart only for yourself.
Never chart for someone else.
You are accountable for information you enter into
chart.

 Avoid using generalized, empty phrases such as

status unchanged or had good day.

Begin each entry with time, and end with your

signature and title.
Do not wait until end of shift to record important
changes that occurred several hours earlier. Be
sure to sign each entry.
For computer documentation keep your
password to yourself.
Maintain security and confidentiality.
Once logged into the computer do not leave the
computer screen unattended.

Reme
mber!

Somethi
ng that
is NOT
written
is
conside
red as

NURS
ING
PROC
ESS

History
The term NURSING PROCESS was first
used/mentioned by Lydia Hall, a nursing theorist,
in 1955 wherein she introduced 3 STEPs:
observation, administration of care and validation.
Since then, nursing process continue to evolve: it
used to be a 3-step process, then a 4-step process
(APIE), then a 5-step (ADPIE), now a 6-step
process (ADOPIE) ASSESSMENT, DIAGNOSIS,
OUTCOME IDENTIFICATION, PLANNING,
IMPLEMENTATION and EVALUATION.

NURSING PROCESS
is a systematic, organized method
of planning, and providing quality
and individualized nursing care.
it is synonymous with the PROBLEM
SOLVING APPROACH that directs
the nurse and the client to
determine the need for nursing
care, to plan and implement the
care and evaluate the result.
It is a G O S H approach (goaloriented, organized, systematic
and humanistic care) for efficient
and effective provision of nursing
care.

*characteristic of
Nursing Process

Cyclic and
Dynamic in
nature
Involves skill in
Decision-making
Uses Critical

Purpose of
Nursing Process:
To identify a clients
health status; his
Actual/Present and
potential/possible
health problems or
needs.
To establish a plan of
care to meet identified
needs.
To provide nursing

Assessment

Evaluation

Diagnosis

Implementati
on

Outcome Identi
fication

Planning

ASSESSMENT
First Step in the Nursing Process
it is systematic and continuous collection, validation and
communication of client data as compared to what is standard/norm.
it includes the clients perceived needs, health problems, related
experiences, health practices, values and lifestyles.
Purpose:
To establish a data base (all the information about the client):

nursing health history

physical assessment
the physicians history & physical examination
results of laboratory & diagnostic tests
material from other health personnel

4 Types of Assessment:
a. Initial assessment assessment
performed within a specified time on
admission
Ex: nursing admission assessment
b. Problem-focused assessment use to
determine status of a specific problem
identified in an earlier assessment
Ex: problem on urination-assess on fluid
intake & urine output hourly

c. Emergency assessment rapid

assessment done during any
physiologic/physiologic crisis of the
client to identify life threatening
problems.
Ex: assessment of a clients airway,
breathing status & circulation after a
cardiac arrest.
d. time-lapsed assessment
reassessment of clients functional
health pattern done several months
after initial assessment to compare
the clients current status to baseline
data previously obtained.

ACTIVITIES
Collection of data
Validation of data
Organization of data
Analyzing of data
Recording/documentation of data

TYPES OF DATA

1.Subjective Data
(Symptoms)
e.g. I feel hot.

2. Objective Data (Signs)

e.g. T= 38.5C, warm to
touch skin

Interview

Methods of Data Collection

Observation
Examination

SOURCES OF
Primary source
- DATA
client (best source of
data)

Secondary
sources
indirect sources
e.g. family members,
-support people,
-client records (medical
records, records of therapies
by other health professionals
and laboratory records),
-health care
professionals,
- literature

Diagnosis
Second Step in the Nursing
Process
- the process of reasoning or the clinical act of
identifying problems

Purpose: To identify health

care needs and prepare a
Nursing Diagnosis.

Components of a nursing diagnosis:

PES or PE

Problem statement/diagnostic
label/definition = P
Etiology/related factors/causes =
E
Defining characteristics/signs and
symptoms = S

Types of Nursing Diagnosis

1. Actual Nursing Diagnosis
(Problem + Etiology + S/S)
e.g.
Impaired verbal communication
r/t cultural differences as
manifested by inability to speak
English
Alteration in comfort, pain /
associated with / abdominal
incision / as manifested by /
muscle guarding and grimace
Altered thermoregulation, /
related to infection / as
manifested by / high grade fever

3. Risk Nursing diagnosis (Problem + Risk Factors)

e.g.
Risk for Constipation r/t inactivity and insufficient
fluid intake
Risk for infection r/t compromised immune system.
Risk for Impaired skin integrity (left ankle) r/t
decrease peripheral circulation in diabetes.

Situation:
Madam Mariam,35 years of laundry woman
seeks consultation at the Al Yousif Hospital
due to fever 2 days PTA. She verbalizes: I
suddenly felt cold and shiver, headache and I
feel hot also after I finished my laundry. She
has 3 children she walks off to school
everyday before she goes to work
VS: T=39.2C RR = 35 P = 96; With flush skin
and warm to touch, teary eyed and with dry
lips and mucous membrane.
Nsg Dx: ?
Hyperthermia r/t environmental condition
AMB T = 39C, flush skin, warm to touch,
teary eyed and dry lip and mucous
membrane.

 A Nurse
will
always
give us
hope,

THAN
K
YOU!