Nursing documentation (ND) involves recording a patient's care and is important for communication, facilitating good care, and meeting legal standards. Accurate ND describes assessments, interventions, and outcomes; and information reported to physicians. Benefits include providing a record of critical thinking, reflecting care quality, and demonstrating nursing's unique contributions. Principles include being comprehensive, reflecting standards, and having identifying information. Inaccurate examples lack details, while accurate examples fully describe a patient's condition and care.

1. Documentation Muhammad Rehan RN, Bsc.Nursing

2. Objectives Define nursing documentation (ND) Purpose of ND Advantage of nursing documentation Principle of ND Example of inaccurate & accurate ND Different record keeping documents. Consequences of inaccurate ND

3. Nursing Documentation Any written or electronically generated information about a client that describes the care or service provided to that client. “ Client” refers to individuals, families, groups, populations or entire communities who require nursing expertise. College of Registered Nurses of British Columbia

4. Nursing documentation clearly describes: An assessment of the client’s health status, nursing interventions carried out, and the impact of these interventions on client outcomes; Information reported to a physician or other health care provider.

5. To facilitate communication To promote good nursing care To meet professional and legal standards Purpose for documentation

6. Benefits of the Nursing Notes Nursing documentation provides: An account of judgment Critical thinking used in the nursing process.

7. Cont… Accurate, timely documentation reflects care provided: Professional, legislative, & agency standards Enhance nursing care Facilitate communication b/w nurses & other health care providers.

8. Cont… It also reflects the application of : Nursing knowledge Nursing skills & judgment Established accountability Conveys the unique contribution of the nursing to health care

9. Documentation Principles Comprehensive and flexible Quality and continuity Track patient outcomes Reflect current standards Patient identification on every page of the record Date, time and name/initials.

10. Guidelines For Documentation Factual Accurate Complete Current Organized

11. How to writ nurses’ notes A = Airway B = Breathing C = Circulation D = Drainage E = Eliminations F = Fluids G = GCS

12. Inaccurate Example Mr. X received from morning staff in well condition. Well oriented, eating well. Vital signs checked & recorded. Physician checked the pt, no any further order. Continue same RX.

13. Accurate Example Mr. X. received from Night shift. Oriented to time, place & person. Breathing spontaneously on room air, RR=20/m. B.P 110/ 70mmgh, pulse=80/m. chest tube in placed with bubbling & column movement present. catheter in placed urine output 30ml/hr, stool passed normally. IV fluids 100ml / hr continue for 24 hrs.________ A.Razzak.

14. Record Keeping Forms Nursing history (HX) Graphic or flow sheet Medication administration record Nursing KARDEX Standardized care plans Discharge summary

15. Narrative Documentation Problem oriented medical records (POMR) Database Problem list Nursing care plan Progress note Source records

16. Progress Notes Soap(IE) Subjective Objective Assessment Plan INTERVENTION Evaluation Pie Problem, intervention, evaluation Dar: Data, action, response

17. Consequences Of Inadequate Documentation Fragmented care Repetition of tasks Delayed therapy Omitted therapy Delayed recovery

18. Refrences DUGas, B., Esson, L. & Ronaldson, S. (1999). Nursing Foundation: A Canadian Perspective. Scarborough: Prentice Hall Canada, P. 480 College of RN of Nova Scotia

19. Quotation of the Day You ask me why I do not write something....I think one's feelings waste themselves in words, they ought all to be distilled into actions and into actions which bring results. Florence Nightingale