The document discusses the importance of documentation in therapeutic communication within nursing practice, highlighting its role in professional responsibility, communication, education, and legal standards. It covers various aspects of documentation, including its use in client care, research, informed consent, and advanced directives, while also outlining effective documentation practices and methods. Additionally, the document emphasizes the significance of accurate record-keeping for reimbursement and accreditation, detailing different documentation methods such as narrative and focus charting.

1. Documentation as
Communication
Therapeutic Communication in Professional Nursing Practice
NRSG 4103

2. Documentation
Written evidence of:
 The interactions between and among health care professionals,
clients, their families, and health care organizations.
 The administration of tests, procedures, treatments, and client
education.
 The results of, or client’s response to, diagnostic tests and
interventions

3. Purposes of Documentation
 Professional responsibility
 Accountability
 Communication
 Education
 Research
 Satisfaction of Legal and Practice standards

‫المهنية‬ ‫المسؤولية‬

‫المساءلة‬

‫تواصل‬

‫تعليم‬

‫بحث‬

‫والممارسة‬ ‫القانونية‬ ‫بالمعايير‬ ‫الرضا‬

4. Documentation as Communication
 Documentation is a communication method that confirms the care
provided to the client.
 It clearly outlines all important information regarding the client.
.‫للعميل‬ ‫المقدمة‬ ‫الرعاية‬ ‫تؤكد‬ ‫اتصال‬ ‫وسيلة‬ ‫هو‬ ‫التوثيق‬
.‫بالعميل‬ ‫المتعلقة‬ ‫الهامة‬ ‫المعلومات‬ ‫جميع‬ ‫بوضوح‬ ‫ويحدد‬

5. Documentation as Education
 The medical record can be used by health care students as a
teaching tool.
 It is the main source of data for clinical research.
.‫تعليمية‬ ‫كأداة‬ ‫الطبي‬ ‫السجل‬ ‫استخدام‬ ‫الصحية‬ ‫الرعاية‬ ‫لطالب‬ ‫يمكن‬
.‫السريري‬ ‫للبحث‬ ‫للبيانات‬ ‫الرئيسي‬ ‫المصدر‬ ‫هو‬ ‫هذا‬

6. Documentation & Research
 The medical record is a main source of data for clinical research.

7. Legal & Practice Standards
‫والممارسة‬ ‫القانونية‬ ‫المعايير‬
 Nurses are responsible for assessing and documenting that the
client has an understanding of treatment prior to intervention.
 Two indicators of the above are Informed Consent and
Advance Directives
‫المسبقة‬ ‫والتوجيهات‬ ‫المستنيرة‬ ‫الموافقة‬ ‫هما‬ ‫سبق‬ ‫لما‬ ‫مؤشران‬ ‫هناك‬

8. Informed Consent
 A competent client’s ability to make health care decisions based
on full disclosure‫كشف‬ of the benefits, risks, and potential
consequences of a recommended treatment plan.
 The client’s agreement to the treatment as indicated by the
client’s signing‫توقيع‬ a consent form.
•
‫عن‬ ‫الكامل‬ ‫الكشف‬ ‫على‬ ً
‫ء‬‫بنا‬ ‫الصحية‬ ‫الرعاية‬ ‫قرارات‬ ‫اتخاذ‬ ‫على‬ ‫المختص‬ ‫المريض‬ ‫قدرة‬
.‫بها‬ ‫الموصى‬ ‫العالج‬ ‫لخطة‬ ‫المحتملة‬ ‫والعواقب‬ ‫والمخاطر‬ ‫الفوائد‬
•
.‫الموافقة‬ ‫نموذج‬ ‫على‬ ‫العميل‬ ‫توقيع‬ ‫خالل‬ ‫من‬ ‫موضح‬ ‫هو‬ ‫كما‬ ‫العالج‬ ‫على‬ ‫المريض‬ ‫موافقة‬

9. Advanced Directives‫توجيهات‬
Written instructions about a client’s health care
preferences regarding life-sustaining measures.
Allows clients, while competent, to participate in end-
of-life decisions.
.‫الحياة‬ ‫على‬ ‫الحفاظ‬ ‫بتدابير‬ ‫يتعلق‬ ‫فيما‬ ‫للمريض‬ ‫الصحية‬ ‫الرعاية‬ ‫تفضيالت‬ ‫حول‬ ‫مكتوبة‬ ‫تعليمات‬
.‫الحياة‬ ‫نهاية‬ ‫قرارات‬ ‫في‬ ‫بالمشاركة‬ ،‫كفاءتهم‬ ‫من‬ ‫الرغم‬ ‫على‬ ،‫للمرضى‬ ‫يسمح‬

10. Documentation & Reimbursement
‫السداد‬ ‫و‬ ‫التوثيق‬
 Accreditation and reimbursement‫داد‬mmmm‫الس‬
agencies require accurate and thorough
documentation of the nursing care
rendered ‫المقدمه‬and the client’s response to
interventions. ‫للرعاية‬ً ‫وشامال‬ ‫ًا‬‫ق‬‫دقي‬ ‫ًا‬‫ق‬‫توثي‬ ‫والسداد‬ ‫االعتماد‬ ‫وكاالت‬ ‫تتطلب‬
‫للتدخالت‬ ‫العميل‬ ‫واستجابة‬ ‫المقدمة‬ ‫التمريضية‬.

11. Reimbursement /
‫السداد‬ ‫التعويض‬
1
:‫العام‬ ‫التعريف‬ .
‫نفقات‬ ‫مقابل‬ ‫مؤسسة‬ ‫أو‬ ‫لشخص‬ ‫المال‬ ‫دفع‬ ‫إعادة‬ ‫عملية‬ -
ً‫ا‬‫مسبق‬ ‫دفعها‬ ‫تم‬
‫تكبدها‬ ‫تم‬ ‫التي‬ ‫التكاليف‬ ‫تسديد‬ -
2
:‫الصحية‬ ‫الرعاية‬ ‫مجال‬ ‫في‬ .
:‫تعويض‬ ‫خالله‬ ‫من‬ ‫يتم‬ ‫دفع‬ ‫نظام‬ -
‫الصحية‬ ‫الرعاية‬ ‫نفقات‬ ‫عن‬ ‫المرضى‬ *
‫المقدمة‬ ‫الخدمات‬ ‫عن‬ ‫الصحية‬ ‫الرعاية‬ ‫مقدمي‬ *
‫العالجية‬ ‫التكاليف‬ ‫عن‬ ‫المستشفيات‬ *
3
:‫التعويض‬ ‫أنواع‬ .
‫للمستشفى‬ ‫التأمين‬ ‫شركة‬ ‫من‬ :‫مباشر‬ ‫تعويض‬ -
‫استرداد‬ ‫ثم‬ ‫المريض‬ ‫دفع‬ :‫مباشر‬ ‫غير‬ ‫تعويض‬ -
‫المبلغ‬
‫التأمينية‬ ‫التغطية‬ ‫حسب‬ ‫كلي‬ ‫أو‬ ‫جزئي‬ ‫تعويض‬ -
4
:‫التعويض‬ ‫مصادر‬ .
‫الصحي‬ ‫التأمين‬ ‫شركات‬ -
‫(مثل‬ ‫حكومية‬ ‫برامج‬ -
Medicare &
Medicaid
)
‫المدارة‬ ‫الصحية‬ ‫الرعاية‬ ‫منظمات‬ -
‫المرضى‬ ‫من‬ ‫الذاتي‬ ‫الدفع‬ -

12. Principles of Effective Documentation
 Assessment.
 Nursing Diagnosis.
 Planning and outcome identification.
 Implementation.
 Evaluation.
 Revisions of planned care.
Elements of nursing process needed to
be made evident‫واضح‬ in documentation include:

13. Elements of Effective Documentation
 Use a common vocabulary.
 Write legibly and neatly. ‫ومرتب‬ ‫مقروء‬ ‫بشكل‬ ‫اكتب‬
 Use only authorized abbreviations and symbols.
 Document accurately and completely, including any errors.
To ensure effective documentation, nurses should:
•
.‫شائعة‬ ‫مفردات‬ ‫استخدم‬
•
.‫ومرتب‬ ‫مقروء‬ ‫بشكل‬ ‫اكتب‬
•
‫االختصارات‬ ‫فقط‬ ‫استخدم‬
.‫المعتمدة‬ ‫والرموز‬
•
‫في‬ ‫بما‬ ،‫كامل‬ ‫وبشكل‬ ‫بدقة‬ ‫التوثيق‬
.‫أخطاء‬ ‫أي‬ ‫ذلك‬

14. Methods of Documentation
 Narrative Charting ‫بياني‬ ‫رسم‬
‫السردي‬
 Source-oriented charting
 Problem-oriented charting
 PIE charting
 Focus charting
 Charting by exception‫استثناء‬
 Computerized documentation
 Critical pathways‫مسارات‬

15. Focus charting‫التركيز‬ ‫مخطط‬
Focus Charting - is a method for organizing health information in the individual's
record. It is a systematic approach ‫منهجي‬ ‫نهج‬ to documentation, using nursing
terminology ‫المصطلحات‬to describe individual's health status and nursing action.

16. Narrative Charting
‫السردي‬ ‫البياني‬ ‫الرسم‬
 This traditional method of
nursing documentation takes the
form of a story written in
paragraphs.
 Before the advent ‫ظهور‬of flow
sheets, this was the only method
for documenting care.
.‫فقرات‬ ‫في‬ ‫مكتوبة‬ ‫قصة‬ ‫شكل‬ ‫التمريض‬ ‫لتوثيق‬ ‫التقليدية‬ ‫الطريقة‬ ‫هذه‬ ‫تأخذ‬
‫الرعاية‬ ‫لتوثيق‬ ‫الوحيدة‬ ‫الطريقة‬ ‫هي‬ ‫هذه‬ ‫كانت‬ ،‫التدفق‬ ‫جداول‬ ‫ظهور‬ ‫قبل‬

17. ‫المشكلة‬ ‫نحو‬ @‫ه‬‫الموج‬ ‫البياني‬ ‫الرسم‬
Problem-Oriented Charting
 A narrative recording‫روائي‬ ‫جيل‬mm‫تس‬ by each member
(source) of the health care team on separate records.
 Focuses on the client’s problem and employs ‫يوظف‬a
structured, logical format called SOAP charting:
 S: Subjective data (what the client states)
 O: Objective data (what is
observed/inspected)
 A: Assessment
 P: Plan

18. PIE Charting
 Problem
 Intervention
 Evaluation
PCA (patient controlled analgesia)
CPM( continuous passive motion‫الحركة‬ )

19. Focus Charting
 A documentation method that uses a column format to
chart data, action, and response (DAR).

20. Charting by Exception‫استثناء‬
 A documentation method that requires
the nurse to document only
deviations‫االنحرافات‬ from pre-
established‫مسبقا‬ ‫محددة‬ norms‫القواعد‬.
‫عن‬ ‫فقط‬ ‫االنحرافات‬ ‫توثيق‬ ‫الممرضة‬ ‫من‬ ‫تتطلب‬ ‫توثيق‬ ‫طريقة‬
.‫ًا‬‫ق‬‫مسب‬ ‫المحددة‬ ‫المعايير‬

21. Computerized Documentation:
Advantages
 Decreased documentation time.
 Increased legibility and accuracy.
 Clear, decisive‫حاسم‬ , and concise words.
.‫التوثيق‬ ‫وقت‬ ‫تقليل‬
.‫والدقة‬ ‫الوضوح‬ ‫زيادة‬
‫وموجزة‬ ‫وحاسمة‬ ‫واضحة‬ ‫كلمات‬
.

22. Computerized Documentation:
Advantages
 Statistical analysis of data.
 Enhanced implementation of the nursing process.
 Enhanced decision making.
 Multidisciplinary networking.
•
.‫للبيانات‬ ‫اإلحصائي‬ ‫التحليل‬
•
‫عملية‬ ‫تنفيذ‬ ‫تعزيز‬
.‫التمريض‬
•
.‫القرار‬ ‫صنع‬ ‫عملية‬ ‫تعزيز‬
•
‫متعددة‬ ‫شبكات‬
.‫التخصصات‬

23. Critical Pathways
 A comprehensive, standard plan of care
for specific case situations.
 The pathway is monitored to ensure
that interventions are performed on
time and client outcomes are achieved
on time.

24. Forms for Recording Data
 Kardex
) Kardex is a desktop file system that gives a brief overview of each patient and is
updated every shift. (
 Flow Sheets
A flow sheet is simply a one- or two-page form that gathers all the important data
regarding a patient's condition
 Nurse’s Progress Notes
 Discharge Summary

25. Kardex
 A summary worksheet reference of basic information
that traditionally is not part of the record. Usually
contains:
Client data (name, age, marital status, religious
preference, physician, family contact).
Medical diagnoses: listed by priority.
Allergies.
Medical orders (diet, IV therapy, etc.).
Activities permitted‫يسمح‬.

26. Flow Sheets
 Vertical or horizontal columns for recording dates and
times and related assessment and intervention
information. Also included are notes on:
Client teaching.
Use of special equipment.
IV Therapy.

27. Nurse’s Progress Notes
Used to document:
Client’s condition, problems, and complaints.
Interventions.
Client’s response to interventions.
Achievement of outcomes‫النتائج‬ ‫تحقيق‬.

28. Discharge Summary
Highlights client’s illness and course of care. Includes:
Client’s status at admission and discharge.
Brief summary of client’s care.
Intervention and education outcomes.
Resolved problems and continuing care needs.
Client instructions regarding medications, diet, food-drug
interactions, activity, treatments, follow-up and other special needs.

29. Trends in Documentation
‫التوثيق‬ ‫في‬ ‫االتجاهات‬
 Nursing Diagnoses.
 Nursing Intervention Classification.
 Nursing Outcomes Classification.

30. Nursing Diagnoses
 A clinical judgment‫قرار‬ about individual, family, or
community responses to actual or potential health
problems or life processes.

31. Nursing Intervention Classification
 A comprehensive standardized language for
nursing interventions organized in a three-level
taxonomy. ‫مستويات‬ ‫ثالثة‬ ‫من‬ ‫تصنيف‬ ‫في‬ ‫المنظمة‬ ‫التمريضية‬ ‫للتدخالت‬ ‫شاملة‬ ‫موحدة‬ ‫لغة‬.

32. Nursing Outcomes Classification
 A classification system that comprises‫تضم‬ outcome labels
and corresponding definitions, measures, indicators, and
references.
‫ومراجع‬ ‫ومؤشرات‬ ‫ومقاييس‬ ‫تعريفات‬ ‫من‬ ‫يقابلها‬ ‫وما‬ ‫نتائج‬ ‫مسمى‬ ‫يضم‬ ‫تصنيف‬ ‫نظام‬.

33. Nursing Outcomes Classification (NOC)
‫نتائج‬ ‫وتوثيق‬ ‫لتقييم‬ ‫يستخدم‬ ‫موحد‬ ‫تصنيف‬ ‫نظام‬ ‫وهو‬ ،‫التمريضية‬ ‫النتائج‬ ‫تصنيف‬
‫التمريضية‬ ‫الرعاية‬.
1
: .
‫التي‬ ‫للنتائج‬ ‫ومنظم‬ ‫شامل‬ ‫تصنيف‬ ‫نظام‬ ‫هو‬ ‫التعريف‬
.‫التمريضية‬ ‫للتدخالت‬ ‫نتيجة‬ ‫المريض‬ ‫يحققها‬ ‫أن‬ ‫يمكن‬

2
: .
‫الرئيسية‬ ‫األهداف‬

-
‫التمريضية‬ ‫الرعاية‬ ‫فعالية‬ ‫قياس‬

-
‫الممرضين‬ ‫بين‬ ‫التواصل‬ ‫لغة‬ ‫توحيد‬

-
‫المريض‬ ‫حالة‬ ‫تطور‬ ‫توثيق‬

-
‫التمريضية‬ ‫الرعاية‬ ‫جودة‬ ‫تقييم‬

3
: .
‫النظام‬ ‫مكونات‬

-
‫للمريض‬ ‫المتوقعة‬ ‫النتائج‬

-
‫التقدم‬ ‫لقياس‬ ‫المؤشرات‬

-
‫الحالة‬ ‫لتقييم‬ ‫مقاييس‬

-
‫التحسن‬ ‫من‬ ‫مختلفة‬ ‫مستويات‬
4
: .
‫الرئيسية‬ ‫المجاالت‬
-
‫الوظيفية‬ ‫الصحة‬
-
‫النفسية‬ ‫الصحة‬
-
‫االجتماعية‬ ‫النفسية‬ ‫الصحة‬
-
‫وسلوكياته‬ ‫المريض‬ ‫معرفة‬
-
‫للمريض‬ ‫الصحي‬ ‫اإلدراك‬
5
: .
‫الفوائد‬
-
‫التمريضية‬ ‫الرعاية‬ ‫جودة‬ ‫تحسين‬
-
‫الصحية‬ ‫الرعاية‬ ‫مقدمي‬ ‫بين‬ ‫التواصل‬ ‫تسهيل‬
-
‫النتائج‬ ‫لتقييم‬ ‫موحدة‬ ‫معايير‬ ‫توفير‬
-
‫األدلة‬ ‫على‬ ‫المبنية‬ ‫الممارسة‬ ‫تعزيز‬

34. Summary Reports
 The outlining of information pertinent to the
client’s needs as identified by the nursing
process.
 Commonly ‫عاده‬given at end-of-shift.

35. Walking Rounds
 A reporting method used when the members of the
care team walk to each client’s room and discuss
care and progress with each other and with the
client.
‫غرفة‬ ‫إلى‬ ‫الرعاية‬ ‫فريق‬ ‫أعضاء‬ ‫يذهب‬ ‫عندما‬ ‫ستخدم‬ُ‫ت‬ ‫التقارير‬ ‫إعداد‬ ‫طريقة‬
‫العميل‬ ‫ومع‬ ‫البعض‬ ‫بعضهم‬ ‫مع‬ ‫والتقدم‬ ‫الرعاية‬ ‫ويناقشون‬ ‫عميل‬ ‫كل‬.

36. Telephone Reports and Orders
 Telephone communications are another way nurses:
Report transfers.
Communicate referrals‫اإلحاالت‬.
Obtain client data.
Solve problems.
Inform a client’s family members regarding a change in
client’s condition.

37. Incident Reports
‫الحوادث‬ ‫تقارير‬
 The documentation of any unusual
occurrence or accident in the
delivery of client care, such as falls
or medication errors.

38. Review Question
1. If you make a mistake in a record how should it be
corrected?
A) with correction fluid
B) scribble it out
C) put a single line through the record
D) tell your mentor
‫تصحيحه؟‬ ‫يجب‬ ‫فكيف‬ ‫السجالت‬ ‫أحد‬ ‫في‬ ‫أخطأت‬ ‫إذا‬
)
‫التصحيح‬ ‫سائل‬ ‫مع‬ ‫أ‬
)
‫خربشتها‬ ‫ب‬
)
‫السجل‬ ‫خالل‬ ‫واحد‬ ‫سطر‬ ‫وضع‬ ‫ج‬
)
‫معلمك‬ ‫أخبر‬ ‫د‬

39. 2. What colour ink can be used when writing in patients
records?
A)any as long as it is legible
B) black
C) black or dark blue
D) black, blue, green and red

40. 3. Who adopts the approach that ‘if it is not recorded, it has not
happened’.
A) The Nursing and Midwifery Council
B) Courts of law
C) The Data Protection Act
D) The doctors
‫و‬
."‫يحدث‬ ‫لم‬ ‫يسجل‬ ‫لم‬ ‫"إذا‬ ‫منهج‬ ‫يتبنى‬ ‫من‬
‫والقبالة‬ ‫التمريض‬ ‫مجلس‬ )‫أ‬
‫المحاكم‬ )‫ب‬
‫البيانات‬ ‫حماية‬ ‫قانون‬ )‫ج‬
‫األطباء‬ )‫د‬

41. 4. Records should be clear, intelligible‫واضح‬
and _______.
A) accessible
B) available
C) annotated
D) accurate

42. 5.Documentation of the patient assessment or treatment
should be done
A) within one hour of care
B)At the time of care
C) within four hours of care
D)at the end of the shift

43. 6. MAR refers to
A) Medical allergies required
B) Medication administration record
C) Medication and allergies record
D) Medical alert record

44. THANK YOU
!