Nurses document patient care in the electronic medical record system. Documentation includes assessments, interventions, patient responses, medication administration, education provided, and routine checks. Physical assessments are done within 8 hours of admission and every shift, with problems addressed in the problem list. Orders are dated, timed, and read back to ensure accuracy. The problem list guides care and is updated as goals are met or conditions change.

1. Documentation
Documentation is entered through the electronic medical record –
CPSI’s Point of Care (POC) charting system
Documentation occurs following any
• Assessment/nursing intervention
• Patient’s response to treatment/intervention
• Medication administration
• Completion of IV Piggybacks
• Education
• Routine nursing rounds
• PRN medication reassessment
• This is to include the effectiveness of the medication and
relevant assessment information including vital signs, level of
sedation, level of pain, and nausea/vomiting

2. Documentation - Physical Assessment
 A problem oriented assessment is performed in a timely manner
by the RN with a comprehensive initial physical assessment
performed and documented within 8 hours of admission
• Subsequent physical assessments are performed at least every
shift, more often according to unit specific protocol or if patient
condition warrants
 When documenting the Physical Assessment, answer all the
questions on the flowchart that are applicable to the patient
 Injury Risk assessments are documented on admission, daily on
the AM shift, after a fall or change in patient condition, and after
any in house transfer
 Braden Risk assessments are documented on admission and daily
on the AM shift

3. Documentation – Admission Package
 The patient history is recorded within 8 hours of admission on the
Initial Interview section of the Admission Package
• This is where history of present illness, patient & family
history, and referral screening is done
 The Tobacco Cessation Protocol section of the Admission
Package is completed on all patients
• If the patient does not use tobacco, the form will have only that
one question
• If the patient has used tobacco in the last 30 days, more
questions will appear to further assess the patient’s tobacco use
and interventions for quitting

4. Documentation – Admission Package
The Influenza and Pneumococcal Vaccination Protocol section of
the Admission Package is also completed on all patients at
admission
 Each part of this form must be completed down to the
Evaluation, and if the evaluation result is that the vaccination is
indicated (and not refused), the Education and Vaccination Decision
parts must be completed as well
 Once all 5 pages of the Admission Package are completed, the
reflexed orders are sent, the pages are printed and distributed
according to the instructions on each page

5. Documentation – RN Validation
The RN “validation” is documentation that the patient was observed
during the shift by an RN
When an RN “validates” patients, he/she should:
• Address or Evaluate each problem
• Enter diagnosis specific assessment data
• Enter a “note” through nursing activities for any other pertinent
information

6. Documentation - Downtime Procedures
In the event of system or power failure:
• Down time procedures are initiated if CPSI is down longer
than 2 hours
• Paper documentation tools are available in the emergency
box on each unit (on the CD) and on the intranet under
“Downtime Procedures”
Once nursing and multi-disciplinary staff have started
documenting on paper they will continue to document on
paper for the rest of their shift

7. Documentation - Intervention List (MedAct)
The Intervention List (also known as the MedAct) is a list
containing nursing orders either written by the physician or
part of a policy/protocol
 Keeping the list current allows for an accurate, up-to-date
look at the patient’s plan of care
 Interventions are PERFORMED, DISCONTINUED,
COMPLETED, or OTHER
 Documenting PERFORMED marks the intervention has been
done and keeps it on the list as a remaining active order
 Documenting COMPLETED marks the intervention as done
and removes it from the list
 Documenting DISCONTINUED is for interventions that are no
longer part of the patient’s plan of care
 The OTHER option may be changed to suit the situation

8. Documentation - Intervention List (MedAct)
Nursing orders may be entered through the MedAct or from the
Order Entry screen
• The category that nursing orders are entered in through the
Interventions list is very important because it affects the location
of order in the list
Interventions (nursing orders related to a problem) may be
associated to related problems at the time of order entry.
• Nursing orders may be timed to start/stop at a specific time and
will change color if overdue
• This is especially useful for extended tests like 24 hour urine
collection
Verify medications, nursing, and ancillary orders in CPSI before
noting the order off
• When verifying orders entered by a HUC, nurses may delete the
order & reenter it, if it is inaccurate

9. Documentation – Physician Orders
 All orders must be dated and timed
 The date and time must also be noted when orders are
faxed and signed off
 Limit using verbal orders unless necessary
• If physician is on the unit he needs to write the orders
 For verbal or telephone orders or for receiving critical lab
results be sure to use the “READBACK” standard and
document when signing the order
• Repeating the order or results is not sufficient
• Write down the complete order or result then read it back
and receive confirmation

10. Documentation – Problem List
The Problem List is the plan of care for the patient
It is initiated by the RN within 8 hours of admission
Problems have suggested goals
• They are measurable and should be obtainable during this
hospitalization
• These may be customized to the patient during
implementation

11. Documentation - Problem List
Example: Patient admitted with a medical diagnosis of
gastroenteritis – complains of nausea, vomiting, diarrhea, and
abdominal pain
• Problem of ELIMINATION initiated for the patient
• Goals:
 The patient maintains 30 ml of urine per hour
 Stool is normal color, amount, and consistency
 Elimination occurs without pain and/or discomfort
• The first goal may be updated to “Patient will tolerate PO
intake without nausea, vomiting, diarrhea” to better suit
this patient’s condition

12. Documentation – Problem List
 Problems should reflect the patient’s current admission
 Consideration is made of the patient’s medical diagnosis as well
as the patient’s statement of present complaint
 Screenings and special situations may also call for a problem to
be initiated
• Patients screening a level II or III in fall prevention must always have a
POTENTIAL FOR INJURY problem
 New problems may be added during the patient’s stay if the
patient’s condition changes
 Problems are resolved as the patient’s condition improves
• Problems may be re-opened if needed from the PL clipboard at the
top, right of any flowchart

13. Documentation – Problem List
Example: Patient admitted with bronchitis with a statement of
present complaint “my chest hurts when I cough” that is a Level
II fall risk would have problems of Airway Clearance or Breathing
Pattern as well as Alteration in Comfort and Potential for Injury

14. Documentation – Problem List
 Problems are documented on each shift.
• Checking “ADDRESSED” with no further documentation is not
sufficient
 When documenting through the problem list, chart:
• Problem specific assessment data
• Interventions specific to the problem
• Any activities that relate to the problem
 To make documenting interventions easier, nurses may associate
interventions with specific problems
 When documenting on the problem, select Intervention and
Update to see a list of interventions that have been associated
with specific Problems

15. Documentation – Problem List
 Once the appropriate interventions have been selected they
will pop up and may be marked
Performed, Discontinued, Completed, etc.
• Comments may be made on the comment line
 Once documentation on the interventions is complete, the
flowchart will enter the Problem Mode, indicated by a large
red button on the left side of the screen
• Any information entered from the physical
assessment, pharmacy, or education screens while in
PROBLEM MODE will be associated with the selected
problem
 Problem specific documentation can be viewed by printing
the Problem Activity Report under the printing tab

16. Documentation – Problem List
 When finished documenting on one problem, click the Problem
Mode button to turn it off and begin documenting on another
problem
 Using the double “up” arrow allows the nurse to easily return to
the top of the assessment and access the problem list
 Problems are resolved as goals are reached
 All goals must be resolved before resolving the problem itself
 At discharge, all unresolved problems are to be addressed

17. Documentation – Problem List
 Example: Patient being discharged with pain medication. The
problem ALTERATION IN COMFORT may be resolved as long as
the goals are met
 Goals for this patient would include:
• Reports pain is relieved or controlled
• Follows prescribed pharmacological regimen
• Verbalizes methods that provide relief
 A note stating that the patient is compliant with medication
regimen and that pain is controlled with PO medication would be
made when the problem was resolved on discharge