NURSING DOCUMENTATION

and

PREPARED BY:

REMINA G. AYSON R.N.

WHAT
IS

NURSIN G?

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
-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 An accurate account of treatment, care

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 and should demonstrate: the care you have planned and provided
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 omission on your part have not compromised their safety A record of arrangements you have made for the continuing care for the patient

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 line horizontally through it and sign your name at end.

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.

Somethin g that is NOT written is considere d as NOT done at

Remem ber!

NURSI NG 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 (goal-oriented, 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 Thinking skills

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 interventions to meet those needs. To provide an individualized, holistic,

Assessment

Evaluation

Diagnosis

Implementation

Outcome Identification

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= 38.5 C, warm to touch skin

Methods of Data Collection

Interview

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 and excessive perspiration 2.

Potential Nursing diagnosis (Problem + Etiology)

e.g. Possible low self-esteem r/t loss job Possible altered thought processes r/t unfamiliar surroundings Potential skin breakdown r/t physical immobilization in total body cast

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.