This document defines nursing documentation and discusses its purposes and principles. Nursing documentation clearly describes a client's health assessment, nursing interventions, and the impact of those interventions. Accurate documentation facilitates communication, promotes good nursing care, and meets professional standards. It should be comprehensive, of high quality, and reflect current care. Inaccurate documentation can fragment care and delay therapy or recovery. The document provides examples of inaccurate versus accurate nursing notes.

1. DOCUMENTATION
PRESENTED BY;-
SUSHMA
M.SC.(NSG) 1ST YEAR

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.

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. PURPOSES OF DOCUMENTATION
• To facilitate communication
• To promote good nursing care
• To meet professional and legal standards

6. BENEFITS OF NURSING NOTES
Nursing documentation provides:
 An account of judgment
 Critical thinking used in the nursing process.

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

8. Contd..
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 write 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. FOCUS CHARTING
• is a method for organizing health information
in the individual's record. It is a systematic
approach to documentation, using nursing
terminology to describe individual's health
status and nursing action

17. FOCUS
• a key word or diagnostic category from a nursing
diagnosis or collaborative problem on the plan of care
(action plan), i.e. skin integrity, coping, activity
tolerance, self care deficit
• a current individual concern or behavior, i.e. nausea,
chest pain, pre-op teaching, hospital admission
• a sign or symptom of (possible) importance to the
nursing and/or medical diagnosis or treatment plan,
i.e. fever, constipation, hypertension, incontinence,
lethargy
•

18. CONTD..
• an acute change in an individual's condition,
i.e. respiratory distress, seizure, fever,
discomfort
• a significant event in an individual's care, i.e.
begin treatment regimen (oxygen), change in
diet, catheterization
• a key word or phrase indicating compliance
with a standard of care or agency policy, i.e.
self medication teaching plan, transition

19. COMPONENTS OF A FOCUS
NOTE(DAR):
• Data: Subjective and/or objective information
supporting the stated focus or describing
observations at the time of significant events.
• Action: Nursing interventions performed,
planned to be performed, and/or protocols and
procedures initiated.
• Response: Description of individual's response to
medical and/or nursing care. Statement that the
Action Plan of Care outcomes have been attained
or are progressing toward attainment.

20. EXAMPLE
Need: Comfort (or, Relief of pain)
• D - Complaining of continuous, sharp pain in mid-
abdominal incisional area. Crying. "I need
something for pain now!" States pain is 9 on a
scale of 10.
• A - Medicated with Demerol 75mg IM in LUOQ of
left buttock. Repositioned on right side with
pillow to abdomen to help splint wound.
• R - Patient stated pain was "much better" 30
minutes later and rated it 3 on a scale of 10.---N.
Nurse

22. Discharge plan for patient who
undergo Surgery
• H – Health Teachings
• A – Anticipatory Guidance
• S – Spirituality
• M - Medications
• I – Incision in Care
• N - Nutrition
• E - Environment

23. PROGRESS NOTES
Soap(IE)
– Subjective
– Objective
– Assessment
– Plan
– INTERVENTION
– Evaluation
• Pie
– Problem, intervention, evaluation
• Dar: – Data, action, response

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

25. Refrences
• DUGas, B., Esson, L. & Ronaldson, S. (1999).
Nursing Foundation: A Canadian Perspective.
Scarborough: Prentice Hall Canada, P. 480
•