This document defines nursing documentation and discusses its purposes and types. Documentation has several purposes, including communication, education, and providing a legal record. The main types of documentation are recording and charting. The document also examines common documentation systems, do's and don'ts of documentation, forms used, and a nurse's responsibilities regarding documentation.

1. DOCUMENTATION
IN NURSING
FATIN HANANI BINTI ABD JALIL
STAFF NURSE

2. GENERAL OBJECTIVE
 Define documentation
 Enlist purpose of documentation
 Types of documentation
 Explain documentation system
 Do and Don’t
 Discuss forms of documentation
 Nurse’s responsibilities in documentation

3. DEFINITION
Documentation – Documentation is the act
of recording client’s status and care in a
written form.
Documentation is any printed or written
record of activities.

4. PURPOSE OF DOCUMENTATION
 Communication
 Education
 Legal Document
 Quality Assurance
 Research
 Nursing Audit
 Health Care Analysis

5. TYPES OF DOCUMENTATION
1. RECORDING
2. CHARTING
 Recording- is a brief accaount of the personal history, medical
history, result of diagnostic tests, findings in physical
examination, treatment and nursing care, progress note and
condition of discharge.
 Charting- is a permanent, written and complete record of the
health history and sosiological information obtained from a
person admitted to a hospital by listening to him, looking at him
and treating him.

6. DOCUMENTATION SYSTEM
1. Source – Oriented Record
2. Problem – Oriented Medical Record (POMR)
3. Problem, Intervension, Evaluation. (PIE)
4. Focus Charting
5. Charting by Exception (CBE)
6. Computerized documentation and care
management.

7. 1) Source – Oriented record – is a narrative recording by each
member of the health care team on separate document.
2) Problem – Oriented Medical Record (POMR) are organized
around the client’s problem. It employs a structure, logical format,
which focuses on the client;s problem.
3) Problem, Intervension, Evaluation. (PIE) is an acronym for
problems, intervention and evaluation of nursing care this system
was to develop streamline documentation.
4) Focus Charting- highlight the client’s concerns, problems or
strengths. Is a documentation system using column to format data.

8. 5) Charting by Exception (CBE)- is a documentation in which only
abnormal or significant finding or exceptions to norms are recorded.
CBE use pre printed flow sheets to document the most aspects of
care.
6) Computerized documentation- Computer make care planning and
documentation relatively easy. Nurses use computers to store the
client database, add progress.

9. DO’S AND DO NOT’S
DO’S
 Use objective ,specific and factual description
 Correct the charting errors
 Chart all teaching
 Review your notes
 Do support medical necessity

10.  DO NOT’S
 Leave blank space for a colleague to chart later
 Chart in advance of the event
 Use vague terms
 Chart for someone else
 Use patient or client as it is in the chart
 Alter a record, even if requested by a physician
 Record assumption or a word reflecting bias

11. FORMS OF DOCUMENTATION
 Kardexes – Is a concise methof of organizing and recording data about a client,
making information quickly accessible to all health professional. It contains
Client information, list of medical diagnosis on priority, allergies, list of daily
treatment, procedures and measurement of vital sign, procedures order such as
X-ray and lab test.
 Flow Sheets – A simple form that gathers all important data regarding a patient
condition it includes graphic records, medication administration record.
 Progress Notes – Is the notes made by nurses provided information about the
progress a clients is making towards Achieving desired outcome.

12.  Discharge Summary
- Is completed when the patient being discharged and refered to
home. It includes Client instruction about medication, diet,
food drug interaction, etc.

13. Nurse’s Responsibilities In Documenttation
 Should keep under safe custody of nurses
 No individual sheet should be separated
 Not accessible to patients and visitors
 Strangers is not permitted to read records
 Errors in nursing charting must be corrected

14. CONCLUSION
 Documentation is the act of recording clients
status and care in the written form. Clients
records are legal documents that provide
evidence of a client Care.