documentation powerpoint

1. Documentation
BY CAITRÍONA LYNCH

2. According to Potter, et. al. (2006) as cited by Petkovšek-
Gregorin and Skela-Savič (2015) documentation is any form of
written or electronically produced information about a service
user that outlines the service user’s condition, or the care and
services he/she is receiving.
Documentation is used as a method of communicating
important information and instructions about service user’s
and their procedures between nurses and nurses’
communication with the multidisciplinary team. Braaf et. al.

3. Legal Requirement
 It is required by all registered nurses
and midwives to take part in
documentation in the workplace.
 These requirements are set out by
the Nursing and Midwifery Board of
Ireland (NMBI).
 These guidelines were published in
2002, and re-issued in 2015.

4. A patients record should include:
 A detailed assessment of the patients physical, mental and social health.
 If necessary, views/ comments from the family if relevant to the assessment.
 Plan of nursing care plus evidence to support the planned care.
 Notes should be recorded on a frequent basis on how well the care is being implemented, any improvements or deterioration or
change in condition.
 A clear, understandable evaluation to the care provided should be recorded.
 Nurses must ensure their documentation is at a level that reaches the standards set by the Health Information and Quality Authority
(HIQA)

5. All documentation should include:
 Clear and understandable hand-writing.
 If handwriting is unclear, the nurse should write in block capitals or print format
 All writing should be clear enough to show up on photocopied paper. No pencils should be used. This may not show clearly if record is
photocopied this also gives the opportunity for documentation entries to be erased.
 Dates and signatures should be on all pieces of documentation or entries.
 All entries must be in chronological order.
 Also, documentation should be recorded as soon as possible after the care has been provided.
 The patients name and record number should be included on all pages of documentation.
 Any referrals or consultations with other members of the multidisciplinary team should be documented also.

6. Continued…
 All advice, information or instructions given from a nurse to a patient should be
recorded as patient education is a form of an intervention.
 Nurses should not record on behalf of another nurse, but if this is necessary the nurse
should state who they are writing for and why. For example a nurse went who finished
his/her shift and went home remembered important information they had forgotten
to record. The nurse receiving this information records the nurses name, the
information, the time of day it applied to, and why the nurse had not recorded it.
 If an error is made in documenting, brackets should be placed around the error, with
one line through the entry, so the error is still visible. This should also be signed and
dated.
 All students should be supervised while recording in documentation as they are not
held entirely accountable for the record while being supervised.