This document provides guidelines and definitions for nursing documentation. It discusses how documentation includes interactions between health professionals and patients, administered tests and treatments, and patient responses. The patient's medical record contains initial assessments, nursing diagnoses, care plans, provided care, patient outcomes, and discharge abilities. Nursing documentation is part of the clinical record written by nurses regarding a patient's health status, needs, care, and response. Documentation supports that care was given, allows communication, provides legal protection, and supports reimbursement, quality assurance, education, and research. Medical records contain identifying information, diagnoses, health history, treatment plans, assessments, medications, diet, teaching, test results, and discharge summaries. The document outlines general documentation guidelines regarding formatting,

1. DOCUMENTATION

2. Documentation
Is a written evidence of the interactions
between
and among health professionals,
patients, and
their families, and health care
organizations; the administration of
tests, procedures,
treatments, and patient education; and
the
results or patients' responses to them.

3. The patient's medical record includes
documentation of:
a. Initial assessments and reassessments.
b. Nursing diagnoses and/or patients needs.
c. Interventions identified to meet the patients nursing care
needs.
d. Nursing care provided.
e. Patients response to, and the outcomes of the care
provided.
f. Abilities of the patient to manage continuing care needs
after discharge.

4. Nursing Documentation
That part of the clinical record written by nurses
and is the total written information
concerning a patient's health status nursing
needs, nursing care and response to care.

5. Purpose of Documentation
1. Supports and reports that nursing action was performed
and indicates the patient's resulting condition.
“If it isn't documented, it wasn't done“
2. Communication.
3. Legal protection.
4. Reimbursement.
5. Quality Assurance.
6. Education.
7. Research.

6. Contents of a Medical Records

7. 1. Patient identifying information.
2. Name, ID number.
3. Past and current diagnoses.
4. Health care history.
5. Reason for admission.
6. Known allergies and reactions.
7. Consent for treatment.
8. Treatment goals and expected outcomes.
9. Medical, nursing, and other professional
assessments, orders, and plans for care.

8. 10. Current medications.
11. Dietary patterns and restrictions.
12. Patient teaching plans and summaries.
13. Clinical progress notes.
14. Laboratory , radiology, and other diagnostic test
results.
15.Release of information forms.
16. Consultation reports.
17. Transfer summary.
18. Discharge summary.

9. GENERAL
DOCUMENTATION
GUIDELINES

10. 1. Use black permanent ink for entries.
2. Date, time, and sign all entries.
3. Use first initial, last name and title.
4. Entries are to be legible with no blank spaces left on a line or in
any area of the documentation.
If a space is left on a line, draw a line through the space to the
end of the line.
For large areas not used on a form or page, use diagonal lines to
mark through the area.

11. 5. If an error is made, draw a line through the error, and date the line.
Do not attempt to erase, or use the corrector.
6. Do not give opinions, make assumptions, or enter vague,
meaningless statements (e.g., "is a good parent"). Be specific.
7. Use correct grammar, spelling and punctuation.
8. Write patient’s name and other identifying information on each
medical record page.

12. 9. Be sure to use only those abbreviations approved by your
agency/facility.
10. Always record a patient’s non-cooperative/non-compliant
behavior.
11. Never document for someone else or sign another nurse’s
name in any portion of the medical record.
12. Documentation should occur as soon after the care given as
possible. Note problems as they occur, resolutions used and
changes in patient’s status.

13. 13. When leaving messages, document time, name, and title of
person taking message, and telephone number you called.
14. Record patient assessment before and after you administer
medications or other treatments.
15. Document any discussion of questionable medical orders, and
the directions the doctor gave. Include the time and date of
discussion and your actions as a result of the discussion and
consequent directions given.

14. 16. Chart an omission as a new entry. Do not backdate or add to
previously written entries.
17. When an unusual incidence occurs, document the incident on
a special incident form. write what happened to the patient
and actions taken to assure the patient’s well-being in the
medical record.
18. Record only your own observations, actions. If you receive
information from another care giver, state the source of the
information.
• 19. Record the date, time, and content of all telephone patient-
• related communications.

15. GENERAL
DOCUMENTATION
GUIDELINES ON
SYSTEM

16. 1. Use only your user name for entries.
2. Date, time all entries.
3. Use first initial, last name and title in signing.
4. Do not give opinions, make assumptions, or enter
vague, meaningless statements (e.g., "is a good
parent"). Be specific.

17. 5. Use correct grammar, spelling and punctuation.
6. Record patient assessment before and after you
administer medications or other treatments.
7. Document any discussion of questionable medical
orders, and the directions the doctor gave. Include the
time and date of discussion and your actions as a
result of the discussion and consequent directions
given.

18. 8. When an unusual incidence occurs,
document the incident on a special
incident form. write what happened to
the patient and actions taken to
assure the patient’s well-being.
9. Record only your own observations,
actions. If you receive information from
another care giver, state the source of
the information.

19. 10. Record the date, time, and
content of all telephone patient-
related communications.

20. CAUTION:
DO NOT
Use another’s user
name to enter data.

21. CAUTION: DO NOT
discuss patient
information within
hearing range of
the patient or with
unauthorized
personnel.

22. • Thank you .