MICRO TEACHING ON DOCUMENTATION OF NURSING PROCESS Nursing documentation clearly describes: • An assessment of the client’s health status, nursing interventions carried out, and the impact of these interventions on client outcomes; • Information reported to a physician or other health care provider. INTRODUCTION 3. DEFINITION Nursing Documentation: Any written or electronically generated information about a client that describes the care or service provided to that client. “Client” refers to individuals, families, groups, populations or entire communities who require nursing expertise. 4. • To facilitate communication • To promote good nursing care • To meet professional and legal standards PURPOSE FOR DOCUMENTATION 5. Benefits of the Nursing Notes Nursing documentation provides: • An account of judgment • Critical thinking used in the nursing process. 6. Cont… Accurate, timely documentation reflects care provided: • Professional, legislative, & agency standards • Enhance nursing care • Facilitate communication b/w nurses & other health care providers. 7. DOCUMENTATION PRINCIPLES • Comprehensive and flexible • Quality and continuity • Track patient outcomes • Reflect current standards • Patient identification on every page of the record • Date, time and name/initials. 8. GUIDELINES FOR DOCUMENTATION • Factual • Accurate • Complete • Current • Organized 9. CONSEQUENCES OF INADEQUATE DOCUMENTATION • Fragmented care • Repetition of tasks • Delayed therapy • Omitted therapy • Delayed recovery 10. Refrences •DUGas, B., Esson, L. & Ronaldson, S.(1999). Nursing Foundation: A Canadian Perspective. Scarborough: Prentice Hall Canada, P. 480