SlideShare a Scribd company logo
1 of 29
Nursing Documentation
Ahmad Thanin
What is Documentation
Effective communication among health professionals and is a vital to
the quality of client care.
Health personal communicate through :
• Discussion
• Is informal oral consideration of a subject by two or more health care personnel to
identify a problem or establish strategies to resolve a problem
• Reports
• is oral , written, or computer-based communication intended to convey information to
others.
• For instance, nurse always report on clients at the end of hospital work shift.
• Records record
• Is written or computer based the process of making an entry on a client medical
record
Why Nursing Documentation is important 1
•It Helps Communicate Between Health Care Team And Prevents Fragmentation,
Repetition, And Delays In Client Care.
Communication :
•We Use Data From The Client’s Record To Establish Nursing Care Plan For That Client.
Planning Client Care :
•An Audit Is A Review Of Client Records For Quality Assurance Purposes
Auditing Health Agencies :
•The treatment plans for a number of clients with the same health problem can yield
information helpful in treating another client.
Research:
Why Nursing Documentation is important 2
•Students in health disciplines often use client records as educational tools.
•A record can frequently provide a comprehensive view of the client, the illness,
effective treatment strategies, and factors that affect the outcome of the illness.
Education
•Documentation Also Helps A Facility Receive Reimbursement From The Federal
Government And Insurance Companies
Reimbursement :
•The Client Record Is Legal Document And Is Usually Admissible In Court As Evidence.
Legal Documentation :
•Information from records may assist health care planners to identify agency needs,
such as overutilized and underutilized hospital services
Health care analysis:
Documentation Guidelines
Correct Patient identification are on every page of the record.
Never record opinions or assumptions
Do not chart for someone else
Chart as close as possible to the time care was performed.
Document if medications not given or treatment not completed) &
reason & action taken above or beside the entry and signed
Confidentiality of computer records
Personal
password is
needed to enter
and sign off
computer files
After logging on,
never leave a
computer
terminal
unattended
Do not leave
client information
displayed on the
monitor where
others may see it
Know the facility
policy and
procedure for
correcting an
entry error
Assessment
Nursing problem/ Nursing diagnosis
Planning
Implementation
Evaluation
Nursing Process
•Is a systematic collection of data to determine the patient’s health status and to identify any
actual or potential health problems.
Assessment
•Organize, analyze, synthesize, and summarize the assessment data to identify patient strengths
and health problems to formulate nursing diagnoses.
Nursing diagnosis
•Development of goals and a care plan designed to assist the patient in resolving the nursing
diagnoses
Planning
•when you put your care plan into action.
•encompasses all nursing interventions directed at solving the patient’s problem and meeting
health care needs.
Implementation
•During the evaluation, you must decide whether the interventions carried out have enabled the
patient to achieve the desired outcomes.
Evaluation
Admission Nursing
Assessment
An initial database , nursing
history.
The nurse generally records
ongoing assessments or
reassessments on flow
sheets or nursing progress
notes.
Nursing Care plan
The clinical record include evidence of client assessment , nursing diagnoses and/or client
needs , nursing interventions, client outcomes, and evidence of a current nursing care
plan.
Types of
nursing
care plans
• is written for each client.
• the form varies from agency to agency
according to the needs of the client and the
department.
• most forms have three columns :
• one for nursing diagnosis,
• second for expected outcomes,
• third for nursing interventions.
Traditional care plan:
• were developed to save documentation time.
• these plans maybe based on an institution's
standards of practice, thereby helping to
provide a high quality of nursing care.
• must be individualized by the nurse in order
to adequately address individual client needs.
.
standardized care plans:
Tools of Nursing Documentation
•A typical form used to record the initial database obtained from the nursing history and
physical assessment.
Nursing Assessment
•Are forms that provide a quick overview of basic patient care information, often referred
to during change-of-shift reports and throughout the shift?
Kardex
•The purpose of progress notes is to inform ongoing patient problems and needs, pertinent
nursing observation, and progress toward meeting expected outcomes.
Nursing Progress Notes
•a standardized approach to communication which can be used in any situation. It stands
for Introduction, Situation, Background, Assessment and Recommendation
ISBAR
Kardexes
is widely used , concise method of organizing and recording data about a client , making
information quickly accessible to all health professional
it consists of a series of cards kept in a portable index file or on computer-generated
forms and can be quickly accessed to reveal specific data.
it is a temporary worksheet written in pencil for ease in recording frequent changes in
details of a client's care.
The information on kardex may be organized into sections , for example :
• Patient information about the client such as name , room number , age , admission, type of surgery and date.
• Allergies
• list of medication , with the date of order and the times of administration for each.
• list of intravenous fluid , with dates of infusion.
• list of daily treatment and procedure , such as irrigation , dressing change
• list of diagnostic procedures ordered such as x-ray or laboratory test. –
• A problem list , stated goal, and approaches of nursing goal
• A flow sheet enable nurses to record nursing data quickly and concisely and provides an easy to read record
of the client's condition over time.
Flow sheets:
• indicate body temperature , pulse , respiratory rate , blood pressure and weight. in some agencies may
include admission or postoperative day, bowel movement and activity.
Graphic record:
• all routes of fluid loss or output are measured and recorded.
Intake and output record:
• include designated areas for date of medication order , the expiration date, the medication name and dose.
medication administration record:
• these record may include categories related to stage of skin injury, drainage, odor, culture information and
treatment.
skin assessment record
• progress note made by the nurse provides information about the progress a client is making toward
achieving desired outcomes.
• in addition to assessment and reassessment data progress notes include information about client problems
and nursing intervention.
progress note :
Nursing Discharge / Referral summaries
Discharge note and referral summary are completed when the client is being
discharged and transferred to another institution or to a home setting where a vist
by a community health nurse is required.
If the discharge plan is given directly to the client and family, it is imperative that
instructions be written in terms that can be readily understood.
•( for example : medications , treatments, and activities should be written in layman's terms, and use of
medical abbreviations ( such as ad lib ) should be avoided.
If a client is transferred within the facility or form a long-term facility to a hospital,
a report needs to accompany the client to ensure continuity of care in the new
area.
•it should include all components of the discharge instructions, but also describe the condition of the
client before the transfer.
•any teaching client instruction that has been done should also be described and recorded.
Content of Discharge/Referral summaries 1
Description of client's physical, mental, and emotional status at
discharge or transfer.
Resolve health problems.
Unresolved continuing health problems and continuing care needs
may include a review-of systems checklist.
Treatments that are to be continued.
Current medications.
Content of Discharge/Referral summaries 2
Restrictions that relate to
•activity.
•diet.
•bathing.
Functional self care abilities in terms of vision, hearing, speech, . . . etc.
Comfort level
Support networks.
Client education provided in relation to disease process, special treatment or care, follow up
appointments.
Discharge destination and mode of discharge.
Referral services.
General Guidelines
Write legibly.
•Date and time each entry
•Use correct grammar and spelling
•Chart nursing intervention chronologically.
•Fill each line completely.
Do not leave blank lines between entries. Draw a single line through blank space.
Do not use erasures or correcting fluids.
•A single line should be drawn through and incorrect entry and “error” should be printed
the information contained in their patient health record will be kept confidential.
Make sure your documentation reflects the nursing process and your professional
responsibilities.
Date and Time
• document the date and time of each recording. (e. g. ,
6/2/2017 , 9: 00 AM )
Date:
• follow the facility’s policy about the frequency of
documenting and adjust the frequency as client's condition
indicates;
• for example, a client whose blood pressure is changing
requires more frequent documentation than a client whose
blood pressure is constant.
Timing :
Signature
Each recording on the nursing notes is
signed by the nurse making it.
• includes the name and title; for example, "susan J.
Green, RN" or "SJ Green, RN. "
• some agencies have a signature sheet and after
signing this sheet, nurses can use their initials.
• with computerized charting, each nurse has his or
her own code, which allows the documentation to
be identified
Telephone Reports
Health professionals
frequently report about a
client by the telephone.
The nurse receive a
telephone report should
document
Date
TIME
NAME
SUBJECT
SIGNATURE
TELEPHONE ORDER
Physicians Often Order A Therapy (E. G. , A Medication)
For A Client By Telephone.
Many facilities Allow Only Registered Nurses To Take
Telephone Orders.
While Physician Gives The Order,
• Write It Down And
• Repeat It Back To The Physician
• To confirm Accuracy.
GUIDELINES FOR TELEPHONE ORDER 1
Know the state nursing board’s position on who
can give and accept verbal and phone order.
Know the facility’s policy regarding phone
orders.
Do not accept an order from a prescriber you
do not know.
Ask the prescriber to speak slowly and clearly.
Ask the prescriber to spell out the medication if
you are not familiar with it.
1
2
3
4
GUIDELINES FOR TELEPHONE ORDER 2
Question the drug, dosage, or change if they
seem inappropriate for this client.
Read the order back to the prescriber at the
end.
write the order on the physician’s order sheet.
when writing a dosage always put a number
before a decimal.
follow agency protocol about the prescribes
protocol for signing telephone orders.
5
6
7
8
ISBAR
DO AND DON’T OF NURSING
DOCUMENTATION
DO DON’T
• Chart a change in a client’s condition and show
that follow-up.
• Read the nurses’ notes prior to care to determine
if there has been a change in the client’s
condition.
• Be timely: “but a late entry is better than no
entry”.
• Correct charting errors.
• Chart the client’s response to interventions.
• Review your notes.
• Use objective, specific, and factual descriptions.
• Chart all teaching.
• Leave blank space for a colleague to chart later.
• Chart in advance of the event. (e. g, procedure,
medication).
• Use vague terms.
• Chart for someone else.
• Record assumptions or words reflecting bias.
• Alter a record even if requested by a superior or a
physician.
• Use “patient” or “client” as it is their chart.
REMEMBER
No recording
should be
done before
providing
nursing care.
Not Written
, Not done
Nursing Documentation

More Related Content

What's hot

nursing documentation
nursing documentationnursing documentation
nursing documentation
cjnoyd
 
Documenting And Reporting
Documenting And ReportingDocumenting And Reporting
Documenting And Reporting
Tosca Torres
 
Discharge of a patient
Discharge of a patientDischarge of a patient
Discharge of a patient
Nursing Path
 
Guidelines for recording and reporting
Guidelines for recording and reportingGuidelines for recording and reporting
Guidelines for recording and reporting
Nursing Path
 

What's hot (20)

[1] documentation and reporting
[1] documentation and reporting[1] documentation and reporting
[1] documentation and reporting
 
Nursing empowerment
Nursing empowermentNursing empowerment
Nursing empowerment
 
Documentation in nursing
Documentation in nursingDocumentation in nursing
Documentation in nursing
 
nursing documentation
nursing documentationnursing documentation
nursing documentation
 
Documentation and reporting
Documentation and reportingDocumentation and reporting
Documentation and reporting
 
Documentation and reporting
Documentation and reportingDocumentation and reporting
Documentation and reporting
 
Documentation and Reporting
Documentation and ReportingDocumentation and Reporting
Documentation and Reporting
 
QUALITY INDICATOR IN NURSING.pptx
QUALITY INDICATOR IN NURSING.pptxQUALITY INDICATOR IN NURSING.pptx
QUALITY INDICATOR IN NURSING.pptx
 
Documentation and reporting
Documentation and reportingDocumentation and reporting
Documentation and reporting
 
Documenting And Reporting
Documenting And ReportingDocumenting And Reporting
Documenting And Reporting
 
Documentation
DocumentationDocumentation
Documentation
 
Types of records and common record keeping forms & computerized documenta...
Types of records and common record keeping forms & computerized documenta...Types of records and common record keeping forms & computerized documenta...
Types of records and common record keeping forms & computerized documenta...
 
Documentation and Reporting
Documentation and ReportingDocumentation and Reporting
Documentation and Reporting
 
REPORTING IN NURSING
REPORTING IN NURSINGREPORTING IN NURSING
REPORTING IN NURSING
 
Discharge of a patient
Discharge of a patientDischarge of a patient
Discharge of a patient
 
Documenting and reporting
Documenting and reportingDocumenting and reporting
Documenting and reporting
 
Recording & reporting
Recording & reportingRecording & reporting
Recording & reporting
 
Records and Reports
Records and ReportsRecords and Reports
Records and Reports
 
Ppt discharge of the patient
Ppt discharge of the patientPpt discharge of the patient
Ppt discharge of the patient
 
Guidelines for recording and reporting
Guidelines for recording and reportingGuidelines for recording and reporting
Guidelines for recording and reporting
 

Similar to Nursing Documentation

sara atef case studyد حاتم البيطار زويل اكاديمي .pdf
sara atef case studyد حاتم البيطار زويل اكاديمي .pdfsara atef case studyد حاتم البيطار زويل اكاديمي .pdf
sara atef case studyد حاتم البيطار زويل اكاديمي .pdf
د حاتم البيطار
 
Documentation-and-Reporting students sharing.ppt
Documentation-and-Reporting students sharing.pptDocumentation-and-Reporting students sharing.ppt
Documentation-and-Reporting students sharing.ppt
Anju Kumawat
 

Similar to Nursing Documentation (20)

BPSAC Purnia
BPSAC Purnia BPSAC Purnia
BPSAC Purnia
 
Documentation &.pptx
Documentation &.pptxDocumentation &.pptx
Documentation &.pptx
 
Documentation & Reporting In Nursing Practice.pptx
Documentation & Reporting In Nursing Practice.pptxDocumentation & Reporting In Nursing Practice.pptx
Documentation & Reporting In Nursing Practice.pptx
 
Babitha's Note on documentation
Babitha's Note on documentationBabitha's Note on documentation
Babitha's Note on documentation
 
documentation and reporting in Nursing and other students
documentation and reporting in  Nursing and other studentsdocumentation and reporting in  Nursing and other students
documentation and reporting in Nursing and other students
 
documentation.pptx
documentation.pptxdocumentation.pptx
documentation.pptx
 
Records and reports documtation 1st bsc ppt.pptx
Records and reports documtation 1st bsc  ppt.pptxRecords and reports documtation 1st bsc  ppt.pptx
Records and reports documtation 1st bsc ppt.pptx
 
Dokumentasi keperawatan berkualitas
Dokumentasi keperawatan berkualitasDokumentasi keperawatan berkualitas
Dokumentasi keperawatan berkualitas
 
Patient record system
Patient record system Patient record system
Patient record system
 
Unit vi documentation and reporting
Unit vi   documentation and reportingUnit vi   documentation and reporting
Unit vi documentation and reporting
 
PURPOSES OF DOCUMENTATION.pptx
PURPOSES OF DOCUMENTATION.pptxPURPOSES OF DOCUMENTATION.pptx
PURPOSES OF DOCUMENTATION.pptx
 
V.5 Nursing as a Science, Documenting and Reporting.pptx
V.5 Nursing as a Science, Documenting and Reporting.pptxV.5 Nursing as a Science, Documenting and Reporting.pptx
V.5 Nursing as a Science, Documenting and Reporting.pptx
 
sara atef case studyد حاتم البيطار زويل اكاديمي .pdf
sara atef case studyد حاتم البيطار زويل اكاديمي .pdfsara atef case studyد حاتم البيطار زويل اكاديمي .pdf
sara atef case studyد حاتم البيطار زويل اكاديمي .pdf
 
Advanced practice nurse led clinics March 2010
Advanced practice nurse led clinics March 2010Advanced practice nurse led clinics March 2010
Advanced practice nurse led clinics March 2010
 
Documentation-and-Reporting students sharing.ppt
Documentation-and-Reporting students sharing.pptDocumentation-and-Reporting students sharing.ppt
Documentation-and-Reporting students sharing.ppt
 
Maintenance of records and reports copy
Maintenance of records and reports   copyMaintenance of records and reports   copy
Maintenance of records and reports copy
 
Documentation-and-Reporting.ppt
Documentation-and-Reporting.pptDocumentation-and-Reporting.ppt
Documentation-and-Reporting.ppt
 
Documentation-and-Reporting.ppt
Documentation-and-Reporting.pptDocumentation-and-Reporting.ppt
Documentation-and-Reporting.ppt
 
unit-VI CHN quality assurance.pptx
unit-VI CHN quality assurance.pptxunit-VI CHN quality assurance.pptx
unit-VI CHN quality assurance.pptx
 
Documentation in Physical therapy
Documentation in Physical therapyDocumentation in Physical therapy
Documentation in Physical therapy
 

More from Ahmad Thanin

More from Ahmad Thanin (20)

Abdominal Paracentesis - Nursing Role
Abdominal Paracentesis - Nursing RoleAbdominal Paracentesis - Nursing Role
Abdominal Paracentesis - Nursing Role
 
Methicillin-resistant Staphylococcus Aureus (MRSA)
Methicillin-resistant Staphylococcus Aureus (MRSA)Methicillin-resistant Staphylococcus Aureus (MRSA)
Methicillin-resistant Staphylococcus Aureus (MRSA)
 
Latex Allergy
Latex AllergyLatex Allergy
Latex Allergy
 
Electrical Safety in healthcare.
Electrical Safety in healthcare.Electrical Safety in healthcare.
Electrical Safety in healthcare.
 
H1N1 flu (swine flu) overview
H1N1 flu (swine flu) overviewH1N1 flu (swine flu) overview
H1N1 flu (swine flu) overview
 
Patient Safety and Quality in Home Health Care
Patient Safety and Quality in Home Health CarePatient Safety and Quality in Home Health Care
Patient Safety and Quality in Home Health Care
 
cardiovascular disease.pptx
cardiovascular disease.pptxcardiovascular disease.pptx
cardiovascular disease.pptx
 
DIABETES MELLITUS
DIABETES MELLITUSDIABETES MELLITUS
DIABETES MELLITUS
 
ABG.pptx
ABG.pptxABG.pptx
ABG.pptx
 
Safety Data Sheet ( SDS )
Safety Data Sheet ( SDS ) Safety Data Sheet ( SDS )
Safety Data Sheet ( SDS )
 
Reduce the Risk of Patient Harm Resulting from Falls.pptx
Reduce the Risk of Patient Harm Resulting from Falls.pptxReduce the Risk of Patient Harm Resulting from Falls.pptx
Reduce the Risk of Patient Harm Resulting from Falls.pptx
 
Respiratory Hygiene and Cough Etiquette.pptx
Respiratory Hygiene and Cough Etiquette.pptxRespiratory Hygiene and Cough Etiquette.pptx
Respiratory Hygiene and Cough Etiquette.pptx
 
Cleaning and Decontamination in Hospitals.pptx
Cleaning and Decontamination in Hospitals.pptxCleaning and Decontamination in Hospitals.pptx
Cleaning and Decontamination in Hospitals.pptx
 
The Safe Handling and Disposal of Sharps.pptx
The Safe Handling and Disposal of Sharps.pptxThe Safe Handling and Disposal of Sharps.pptx
The Safe Handling and Disposal of Sharps.pptx
 
Hand hygiene.pptx
Hand hygiene.pptxHand hygiene.pptx
Hand hygiene.pptx
 
Monkeypox Virus
Monkeypox Virus Monkeypox Virus
Monkeypox Virus
 
Basic Microbiology.
Basic Microbiology.Basic Microbiology.
Basic Microbiology.
 
Business Models in Strategic Management.PPTX
Business Models in Strategic Management.PPTXBusiness Models in Strategic Management.PPTX
Business Models in Strategic Management.PPTX
 
Foreign market analysis
Foreign market analysisForeign market analysis
Foreign market analysis
 
Bedsores (pressure ulcers)
Bedsores (pressure ulcers)Bedsores (pressure ulcers)
Bedsores (pressure ulcers)
 

Recently uploaded

Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...
Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...
Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...
Levi Shapiro
 
تقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdf
تقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdfتقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdf
تقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdf
د حاتم البيطار
 

Recently uploaded (20)

Mental Health Startup Pitch Deck Presentation
Mental Health Startup Pitch Deck PresentationMental Health Startup Pitch Deck Presentation
Mental Health Startup Pitch Deck Presentation
 
Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...
Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...
Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...
 
Session-10-Infants-with-Special-meeds.ppt
Session-10-Infants-with-Special-meeds.pptSession-10-Infants-with-Special-meeds.ppt
Session-10-Infants-with-Special-meeds.ppt
 
Importance of Diet on Dental Health.docx
Importance of Diet on Dental Health.docxImportance of Diet on Dental Health.docx
Importance of Diet on Dental Health.docx
 
GOUT and it's Management with All the catagories like; Defination, Type, Sym...
GOUT and it's Management with All the catagories like;  Defination, Type, Sym...GOUT and it's Management with All the catagories like;  Defination, Type, Sym...
GOUT and it's Management with All the catagories like; Defination, Type, Sym...
 
Case Presentation: Severe microcytic hypochromic iron deficiency anemia with ...
Case Presentation: Severe microcytic hypochromic iron deficiency anemia with ...Case Presentation: Severe microcytic hypochromic iron deficiency anemia with ...
Case Presentation: Severe microcytic hypochromic iron deficiency anemia with ...
 
Personnel and Equipment - Code and Rapid Response Workshop
Personnel and Equipment - Code and Rapid Response WorkshopPersonnel and Equipment - Code and Rapid Response Workshop
Personnel and Equipment - Code and Rapid Response Workshop
 
PSYCHOLOGICAL ASPECTS OF REHAB. IN PHYSIOTHERAPY..pdf
PSYCHOLOGICAL ASPECTS OF REHAB. IN PHYSIOTHERAPY..pdfPSYCHOLOGICAL ASPECTS OF REHAB. IN PHYSIOTHERAPY..pdf
PSYCHOLOGICAL ASPECTS OF REHAB. IN PHYSIOTHERAPY..pdf
 
Session-17-KANGAROO-MOTHER-CARE_final-blue.pptx
Session-17-KANGAROO-MOTHER-CARE_final-blue.pptxSession-17-KANGAROO-MOTHER-CARE_final-blue.pptx
Session-17-KANGAROO-MOTHER-CARE_final-blue.pptx
 
Pulse Check Decisions - RRT and Code Blue Workshop
Pulse Check Decisions - RRT and Code Blue WorkshopPulse Check Decisions - RRT and Code Blue Workshop
Pulse Check Decisions - RRT and Code Blue Workshop
 
تقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdf
تقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdfتقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdf
تقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdf
 
Lactation Mraining Management Session-2-Comm-Building-Conf.ppt
Lactation Mraining Management  Session-2-Comm-Building-Conf.pptLactation Mraining Management  Session-2-Comm-Building-Conf.ppt
Lactation Mraining Management Session-2-Comm-Building-Conf.ppt
 
End of Response issues - Code and Rapid Response Workshop
End of Response issues - Code and Rapid Response WorkshopEnd of Response issues - Code and Rapid Response Workshop
End of Response issues - Code and Rapid Response Workshop
 
Navigating Conflict in PE Using Strengths-Based Approaches
Navigating Conflict in PE Using Strengths-Based ApproachesNavigating Conflict in PE Using Strengths-Based Approaches
Navigating Conflict in PE Using Strengths-Based Approaches
 
PhRMA Vaccines Deck_05-15_2024_FINAL.pptx
PhRMA Vaccines Deck_05-15_2024_FINAL.pptxPhRMA Vaccines Deck_05-15_2024_FINAL.pptx
PhRMA Vaccines Deck_05-15_2024_FINAL.pptx
 
The Pfizer testimony by Melissa Mac Atee
The Pfizer testimony by Melissa Mac AteeThe Pfizer testimony by Melissa Mac Atee
The Pfizer testimony by Melissa Mac Atee
 
Technology transfer documentation and strategies
Technology transfer documentation and strategiesTechnology transfer documentation and strategies
Technology transfer documentation and strategies
 
Session-16-HIV-and-Replacement-Feeding-revised-2012.ppt
Session-16-HIV-and-Replacement-Feeding-revised-2012.pptSession-16-HIV-and-Replacement-Feeding-revised-2012.ppt
Session-16-HIV-and-Replacement-Feeding-revised-2012.ppt
 
The Docs PPG - 30.01.2024.pptx..........
The Docs PPG - 30.01.2024.pptx..........The Docs PPG - 30.01.2024.pptx..........
The Docs PPG - 30.01.2024.pptx..........
 
Presentation on Cleft Lip and Cleft Palate
Presentation on Cleft Lip and Cleft PalatePresentation on Cleft Lip and Cleft Palate
Presentation on Cleft Lip and Cleft Palate
 

Nursing Documentation

  • 2. What is Documentation Effective communication among health professionals and is a vital to the quality of client care. Health personal communicate through : • Discussion • Is informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem • Reports • is oral , written, or computer-based communication intended to convey information to others. • For instance, nurse always report on clients at the end of hospital work shift. • Records record • Is written or computer based the process of making an entry on a client medical record
  • 3. Why Nursing Documentation is important 1 •It Helps Communicate Between Health Care Team And Prevents Fragmentation, Repetition, And Delays In Client Care. Communication : •We Use Data From The Client’s Record To Establish Nursing Care Plan For That Client. Planning Client Care : •An Audit Is A Review Of Client Records For Quality Assurance Purposes Auditing Health Agencies : •The treatment plans for a number of clients with the same health problem can yield information helpful in treating another client. Research:
  • 4. Why Nursing Documentation is important 2 •Students in health disciplines often use client records as educational tools. •A record can frequently provide a comprehensive view of the client, the illness, effective treatment strategies, and factors that affect the outcome of the illness. Education •Documentation Also Helps A Facility Receive Reimbursement From The Federal Government And Insurance Companies Reimbursement : •The Client Record Is Legal Document And Is Usually Admissible In Court As Evidence. Legal Documentation : •Information from records may assist health care planners to identify agency needs, such as overutilized and underutilized hospital services Health care analysis:
  • 5. Documentation Guidelines Correct Patient identification are on every page of the record. Never record opinions or assumptions Do not chart for someone else Chart as close as possible to the time care was performed. Document if medications not given or treatment not completed) & reason & action taken above or beside the entry and signed
  • 6. Confidentiality of computer records Personal password is needed to enter and sign off computer files After logging on, never leave a computer terminal unattended Do not leave client information displayed on the monitor where others may see it Know the facility policy and procedure for correcting an entry error
  • 7. Assessment Nursing problem/ Nursing diagnosis Planning Implementation Evaluation
  • 8. Nursing Process •Is a systematic collection of data to determine the patient’s health status and to identify any actual or potential health problems. Assessment •Organize, analyze, synthesize, and summarize the assessment data to identify patient strengths and health problems to formulate nursing diagnoses. Nursing diagnosis •Development of goals and a care plan designed to assist the patient in resolving the nursing diagnoses Planning •when you put your care plan into action. •encompasses all nursing interventions directed at solving the patient’s problem and meeting health care needs. Implementation •During the evaluation, you must decide whether the interventions carried out have enabled the patient to achieve the desired outcomes. Evaluation
  • 9. Admission Nursing Assessment An initial database , nursing history. The nurse generally records ongoing assessments or reassessments on flow sheets or nursing progress notes.
  • 10. Nursing Care plan The clinical record include evidence of client assessment , nursing diagnoses and/or client needs , nursing interventions, client outcomes, and evidence of a current nursing care plan.
  • 11. Types of nursing care plans • is written for each client. • the form varies from agency to agency according to the needs of the client and the department. • most forms have three columns : • one for nursing diagnosis, • second for expected outcomes, • third for nursing interventions. Traditional care plan: • were developed to save documentation time. • these plans maybe based on an institution's standards of practice, thereby helping to provide a high quality of nursing care. • must be individualized by the nurse in order to adequately address individual client needs. . standardized care plans:
  • 12. Tools of Nursing Documentation •A typical form used to record the initial database obtained from the nursing history and physical assessment. Nursing Assessment •Are forms that provide a quick overview of basic patient care information, often referred to during change-of-shift reports and throughout the shift? Kardex •The purpose of progress notes is to inform ongoing patient problems and needs, pertinent nursing observation, and progress toward meeting expected outcomes. Nursing Progress Notes •a standardized approach to communication which can be used in any situation. It stands for Introduction, Situation, Background, Assessment and Recommendation ISBAR
  • 13. Kardexes is widely used , concise method of organizing and recording data about a client , making information quickly accessible to all health professional it consists of a series of cards kept in a portable index file or on computer-generated forms and can be quickly accessed to reveal specific data. it is a temporary worksheet written in pencil for ease in recording frequent changes in details of a client's care. The information on kardex may be organized into sections , for example : • Patient information about the client such as name , room number , age , admission, type of surgery and date. • Allergies • list of medication , with the date of order and the times of administration for each. • list of intravenous fluid , with dates of infusion. • list of daily treatment and procedure , such as irrigation , dressing change • list of diagnostic procedures ordered such as x-ray or laboratory test. – • A problem list , stated goal, and approaches of nursing goal
  • 14. • A flow sheet enable nurses to record nursing data quickly and concisely and provides an easy to read record of the client's condition over time. Flow sheets: • indicate body temperature , pulse , respiratory rate , blood pressure and weight. in some agencies may include admission or postoperative day, bowel movement and activity. Graphic record: • all routes of fluid loss or output are measured and recorded. Intake and output record: • include designated areas for date of medication order , the expiration date, the medication name and dose. medication administration record: • these record may include categories related to stage of skin injury, drainage, odor, culture information and treatment. skin assessment record • progress note made by the nurse provides information about the progress a client is making toward achieving desired outcomes. • in addition to assessment and reassessment data progress notes include information about client problems and nursing intervention. progress note :
  • 15. Nursing Discharge / Referral summaries Discharge note and referral summary are completed when the client is being discharged and transferred to another institution or to a home setting where a vist by a community health nurse is required. If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. •( for example : medications , treatments, and activities should be written in layman's terms, and use of medical abbreviations ( such as ad lib ) should be avoided. If a client is transferred within the facility or form a long-term facility to a hospital, a report needs to accompany the client to ensure continuity of care in the new area. •it should include all components of the discharge instructions, but also describe the condition of the client before the transfer. •any teaching client instruction that has been done should also be described and recorded.
  • 16. Content of Discharge/Referral summaries 1 Description of client's physical, mental, and emotional status at discharge or transfer. Resolve health problems. Unresolved continuing health problems and continuing care needs may include a review-of systems checklist. Treatments that are to be continued. Current medications.
  • 17. Content of Discharge/Referral summaries 2 Restrictions that relate to •activity. •diet. •bathing. Functional self care abilities in terms of vision, hearing, speech, . . . etc. Comfort level Support networks. Client education provided in relation to disease process, special treatment or care, follow up appointments. Discharge destination and mode of discharge. Referral services.
  • 18. General Guidelines Write legibly. •Date and time each entry •Use correct grammar and spelling •Chart nursing intervention chronologically. •Fill each line completely. Do not leave blank lines between entries. Draw a single line through blank space. Do not use erasures or correcting fluids. •A single line should be drawn through and incorrect entry and “error” should be printed the information contained in their patient health record will be kept confidential. Make sure your documentation reflects the nursing process and your professional responsibilities.
  • 19. Date and Time • document the date and time of each recording. (e. g. , 6/2/2017 , 9: 00 AM ) Date: • follow the facility’s policy about the frequency of documenting and adjust the frequency as client's condition indicates; • for example, a client whose blood pressure is changing requires more frequent documentation than a client whose blood pressure is constant. Timing :
  • 20. Signature Each recording on the nursing notes is signed by the nurse making it. • includes the name and title; for example, "susan J. Green, RN" or "SJ Green, RN. " • some agencies have a signature sheet and after signing this sheet, nurses can use their initials. • with computerized charting, each nurse has his or her own code, which allows the documentation to be identified
  • 21. Telephone Reports Health professionals frequently report about a client by the telephone. The nurse receive a telephone report should document Date TIME NAME SUBJECT SIGNATURE
  • 22. TELEPHONE ORDER Physicians Often Order A Therapy (E. G. , A Medication) For A Client By Telephone. Many facilities Allow Only Registered Nurses To Take Telephone Orders. While Physician Gives The Order, • Write It Down And • Repeat It Back To The Physician • To confirm Accuracy.
  • 23. GUIDELINES FOR TELEPHONE ORDER 1 Know the state nursing board’s position on who can give and accept verbal and phone order. Know the facility’s policy regarding phone orders. Do not accept an order from a prescriber you do not know. Ask the prescriber to speak slowly and clearly. Ask the prescriber to spell out the medication if you are not familiar with it. 1 2 3 4
  • 24. GUIDELINES FOR TELEPHONE ORDER 2 Question the drug, dosage, or change if they seem inappropriate for this client. Read the order back to the prescriber at the end. write the order on the physician’s order sheet. when writing a dosage always put a number before a decimal. follow agency protocol about the prescribes protocol for signing telephone orders. 5 6 7 8
  • 25. ISBAR
  • 26.
  • 27. DO AND DON’T OF NURSING DOCUMENTATION DO DON’T • Chart a change in a client’s condition and show that follow-up. • Read the nurses’ notes prior to care to determine if there has been a change in the client’s condition. • Be timely: “but a late entry is better than no entry”. • Correct charting errors. • Chart the client’s response to interventions. • Review your notes. • Use objective, specific, and factual descriptions. • Chart all teaching. • Leave blank space for a colleague to chart later. • Chart in advance of the event. (e. g, procedure, medication). • Use vague terms. • Chart for someone else. • Record assumptions or words reflecting bias. • Alter a record even if requested by a superior or a physician. • Use “patient” or “client” as it is their chart.
  • 28. REMEMBER No recording should be done before providing nursing care. Not Written , Not done