Power point presentation

1. PRINCIPLES of NURSING DOCUMENTATION to SAFEGUARD
YOUR PRACTICE

2. OVERVIEW

3. OBJECTIVES
Review the Primary
Purposes of Documentation
Describe the features of
effective documentation
Identify liability issues in
nursing documentation
Discuss strategies to
safeguard your practice

4. Nursing Practice

5. PURPOSES
OF
NURSING
DOCUMEN
TATION
To Ensure Continuity of
Care for the Patient (by
providing information to
other health care
providers)
Provides Valuable Tools
to Refresh Your Memory
if you are ever Brought to
Court

6. Charting Formats
SOAPIE
DAR
Narrative
Exception

7. Purposes of Documentation
(American Nurses Association, 2010)
Communication with Healthcare Team
• Credentialing
• Legal
• Regulation & Legislation
• Reimbursement
• Research
• Quality processes & Performance improvement
Communication with other professionals

8. Features of Effective Documentation
(College of Registered Nurses of Nova Scotia, 2019)
FACTUAL ACCURATE COMPLETE TIMELY
ORGANIZED REFLECTIVE OF
RELEVANT
OBSERVATIONS
SIGNED

10. Identify the
issues

11. Strategies to Safeguard Your
Practice?

12. References
• American Nurses Association (2010). ANA’s Principles for
nursing documentation. Retrieved from
http://www.nursingworld.org/~4af4f2/globalassets/docs
/ana/ethics/principles-of-nursing-documentation.pdf
• College of Registered Nurses of Nova Scotia (2019).
Documentation guidelines for registered nurses.
Retrieved from https://www.nscn.ca/professional-
practice/practice-support/practice-support-
tools/documentation/documentation-guidelines-nurses
• Potter, P.A.,& Perry, A. G. (2010). Canadian Fundamentals
of Nursing (4th ed.). Elsevier: Canada