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  • It is comprehensive but flexible enough to change with changing organizational and policy needs It reflects the quality of care and holds providers accountable for the care they provide. They enable providers to track care and the patients response to interventions. They provide an opportunity for consistency, reflect standards and how they are being met.
  • Factual: objective information from the sensesNo: appears, seems or apparently. Use the client’s words
  • Nursing history: includes relevant bio, hx, current problem, dx. Serves as the baseline for care. Graphic or flow sheet: for routine repetitive care for ease of following normal course. Serves as jumping off point for focused charting. Ht, wt, VS, fluids I&O, ETC Mar: MEDICATIONS TIME, ROUTEDOCUMENTATION PRINCIPLES Comprehensive and flexible Quality and continuity Track patient outcomes Reflect current standards
  • Source records each discipline has its own section for charting. The information about any one problem i.e. tb may be through out the chard unlike a PMOR.
  • Documentation

    1. 1. Documentation Muhammad Rehan RN, Bsc.Nursing
    2. 2. Objectives <ul><li>Define nursing documentation (ND) </li></ul><ul><li>Purpose of ND </li></ul><ul><li>Advantage of nursing documentation </li></ul><ul><li>Principle of ND </li></ul><ul><li>Example of inaccurate & accurate ND </li></ul><ul><li>Different record keeping documents. </li></ul><ul><li>Consequences of inaccurate ND </li></ul>
    3. 3. Nursing Documentation <ul><li>Any written or electronically generated information about a client that describes the care or service provided to that client. </li></ul><ul><li>“ Client” refers to individuals, families, groups, populations or entire communities who require nursing expertise. </li></ul><ul><li>College of Registered Nurses of British Columbia </li></ul>
    4. 4. <ul><li>Nursing documentation clearly describes: </li></ul><ul><li>An assessment of the client’s health status, nursing interventions carried out, and the impact of these interventions on client outcomes; </li></ul><ul><li>Information reported to a physician or other health care provider. </li></ul>
    5. 5. <ul><li>To facilitate communication </li></ul><ul><li>To promote good nursing care </li></ul><ul><li>To meet professional and legal standards </li></ul>Purpose for documentation
    6. 6. Benefits of the Nursing Notes <ul><li>Nursing documentation provides: </li></ul><ul><li>An account of judgment </li></ul><ul><li>Critical thinking used in the nursing process. </li></ul>
    7. 7. Cont… <ul><li>Accurate, timely documentation reflects care provided: </li></ul><ul><li>Professional, legislative, & agency standards </li></ul><ul><li>Enhance nursing care </li></ul><ul><li>Facilitate communication b/w nurses & other health care providers. </li></ul>
    8. 8. Cont… <ul><li>It also reflects the application of : </li></ul><ul><li>Nursing knowledge </li></ul><ul><li>Nursing skills & judgment </li></ul><ul><li>Established accountability </li></ul><ul><li>Conveys the unique contribution of the nursing to health care </li></ul>
    9. 9. Documentation Principles <ul><li>Comprehensive and flexible </li></ul><ul><li>Quality and continuity </li></ul><ul><li>Track patient outcomes </li></ul><ul><li>Reflect current standards </li></ul><ul><li>Patient identification on every page of the record </li></ul><ul><li>Date, time and name/initials. </li></ul>
    10. 10. Guidelines For Documentation <ul><li>Factual </li></ul><ul><li>Accurate </li></ul><ul><li>Complete </li></ul><ul><li>Current </li></ul><ul><li>Organized </li></ul>
    11. 11. How to writ nurses’ notes <ul><li>A = Airway </li></ul><ul><li>B = Breathing </li></ul><ul><li>C = Circulation </li></ul><ul><li>D = Drainage </li></ul><ul><li>E = Eliminations </li></ul><ul><li>F = Fluids </li></ul><ul><li>G = GCS </li></ul>
    12. 12. Inaccurate Example <ul><li>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. </li></ul>
    13. 13. Accurate Example <ul><li>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. </li></ul>
    14. 14. Record Keeping Forms <ul><li>Nursing history (HX) </li></ul><ul><li>Graphic or flow sheet </li></ul><ul><li>Medication administration record </li></ul><ul><li>Nursing KARDEX </li></ul><ul><li>Standardized care plans </li></ul><ul><li>Discharge summary </li></ul>
    15. 15. Narrative Documentation <ul><li>Problem oriented medical records (POMR) </li></ul><ul><ul><li>Database </li></ul></ul><ul><ul><li>Problem list </li></ul></ul><ul><ul><li>Nursing care plan </li></ul></ul><ul><ul><li>Progress note </li></ul></ul><ul><li>Source records </li></ul>
    16. 16. Progress Notes <ul><li>Soap(IE) </li></ul><ul><ul><li>Subjective </li></ul></ul><ul><ul><li>Objective </li></ul></ul><ul><ul><li>Assessment </li></ul></ul><ul><ul><li>Plan </li></ul></ul><ul><ul><li>INTERVENTION </li></ul></ul><ul><ul><li>Evaluation </li></ul></ul><ul><li>Pie </li></ul><ul><ul><li>Problem, intervention, evaluation </li></ul></ul><ul><li>Dar: </li></ul><ul><ul><li>Data, action, response </li></ul></ul>
    17. 17. Consequences Of Inadequate Documentation <ul><li>Fragmented care </li></ul><ul><li>Repetition of tasks </li></ul><ul><li>Delayed therapy </li></ul><ul><li>Omitted therapy </li></ul><ul><li>Delayed recovery </li></ul>
    18. 18. Refrences <ul><li>DUGas, B., Esson, L. & Ronaldson, S. </li></ul><ul><ul><li>(1999). Nursing Foundation: A Canadian Perspective. Scarborough: Prentice Hall Canada, P. 480 </li></ul></ul><ul><ul><li>College of RN of Nova Scotia </li></ul></ul>
    19. 19. Quotation of the Day <ul><li>You ask me why I do not write something....I think one's feelings waste themselves in words, they ought all to be distilled into actions and into actions which bring results. Florence Nightingale </li></ul>