This document discusses healthcare documentation and the nursing process. It defines documentation as written records of interactions between healthcare professionals and clients, as well as test results and treatments. Documentation provides a record of the care provided based on assessments and client responses. Nurses rely on documentation tools that support applying the nursing process in a logical sequence. The nursing process involves assessment, nursing diagnosis, goals and interventions, implementation, and evaluation. Proper documentation is important for accountability, communication, and demonstrating critical thinking. It must be thorough, accurate, and reflective of the care plan.

1. UNIT TWO
RECORDING AND REPORTING
1

2. Documentation
Documentation is defined as written evidence of:
1. The interactions between and among health
professionals, clients, their families, and health
care organizations
2. The administration of tests, procedures,
treatments, and client education
3. The results or client’s response to these
diagnostic tests and interventions
2

3. Cont…d
• Documentation provides written records that
reflect client care provided on the basis of
assessment data and the client’s response to
interventions.
• Nurses rely on documentation tools that support
the implementation of the nursing process.
• These tools are the charting records and systems
that facilitate a logical sequencing of events.
3

4. Cont…d
• All the tools used by nurses to record their nursing
care should form a system.
• Systematic documentation is critical because it
presents the care administered by nurses in a
logical fashion, as follows:
1. Assessment data (obtained by interviewing,
observing, and inspecting) identifies the client’s
specific alterations and provides the foundation of
the nursing care plan.
4

5. Cont…d
2. The risk factors and/or the identified alteration in
the functional health pattern directs the
formulation of a nursing diagnosis.
3. Identifying the nursing diagnosis promotes the
development of the client’s short-term goals, long-
term goals, and expected outcomes, and also
triggers the nursing interventions. These activities
occur during the planning and implementation
phases of the nursing process.
5

6. Cont…d
4. The plan of care identifies the actions necessary
to resolve the nursing diagnosis.
5. Implementation is evidenced by actions the
nurse performed to assist the client in achieving
the expected outcomes.
6

7. Cont…d
• The system becomes a vehicle for expressing each
phase of the nursing process. Nurses rely on
systems that provide thorough, accurate charting
reflective of the nurse’s decision-making ability
and the client’s plan of care. The nurse’s critical-
thinking skills, judgments, and evaluation must be
clearly communicated through proper
documentation.
7

8. Purposes of Health Care Documentation
• Professional responsibility and accountability are two
primary reasons why practitioners document.
• Other reasons to document include communication,
education, research, meeting legal and practice
standards, and reimbursement.
• Documentation is the professional responsibility of all
health care practitioners.
• It provides written evidence of the practitioner’s
accountability to the client, the institution, the
profession, and society.
8

9. 9
TABLE 1
Medical Record Documents
Face sheet Biographical data: name, date of birth, address, phone number, Social Security
number, marital status, employment, race, gender, religion, closest relative.
Consent form Admit: Gives the institution and physician the right to treat.
Surgery: Explains the reason for the operation in lay terms, the risks for
complications, and the client’s level of understanding.
Blood transfusion: Permission to administer blood or blood products.
Medical history
and P/E
Results of the client’s initial history and physical assessment as performed by
the health care provider
Prescriber order
sheet
Medical orders to admit and the treatment plan.
Progress notes Evaluation of the client’s response to treatment; may contain the progress
recording of interdisciplinary practitioners (e.g., dietary or social services)
Nursing plan of
care
Contains the treatment plan (e.g., nursing diagnosis or a problem list, initiation
of standards of care, or protocols)
Discharge plan
and summary
A multidisciplinary form used before discharge from a health care facility
containing a briefsummary of care rendered and discharge instructions (e.g.,
food-drug interactions, referrals or follow-up appointments)

10. Informed Consent
• Informed consent means that the client
understands the reason for and the risks of the
proposed intervention and agrees to the
treatment by signing a consent form.
• Legally, the client must be mentally competent,
and the physician who is to perform the procedure
is responsible for obtaining the client’s informed
consent
10

11. Cont…d
The legal issues of documentation require:
• Legible and neat writing
• Proper use of spelling and grammar
• Use of authorized abbreviations
• Factual and time-sequenced descriptive notations
11

12. Elements of Effective
Documentation
Effective documentation requires:
• Use of a common vocabulary.
• Legibility and neatness.
• Use of only authorized abbreviations and symbols.
• Factual and time-sequenced organization.
• Accurately including any errors that occurred.
12