The document discusses guidelines for nursing documentation. It emphasizes that documentation is an integral part of nursing practice and is necessary for efficient patient care, communication, legal and professional standards, education, and quality improvement. Some of the key guidelines covered include documenting objectively and factually, timely completion of records, following guidelines for corrections, recording patient education, and incident reporting. Thorough and accurate documentation is essential for nursing accountability and high quality patient care.

2. INTRODUCTION
• Quality documentation and reporting are necessary to enhance efficient,
individualized client care (Potter, Perry, Ross-Kerr, & Wood, 2006).
Regardless of the format used to document, the client1’s health-care
record is a formal, legal document that details a client’s care and progress.
Differences in how client health-care records are kept exist across the
multiple settings in which registered nurses (RNs) practice, and each client
care population has its own unique characteristics and expectations. Still,
the foundational principles of nursing documentation apply to every type
of documentation in every practice setting (Guidelines Documentation for
RN, College and Association of Registered Nurses of Alberta 2006).
• Documentation is not separate from care and it is not optional. It is an
integral part of registered nurse practice, and an important tool that RNs
use to ensure high-quality client care.
• The term “documentation” as used in these guidelines refers to: any
written or electronically generated information about a client that
describes client status or the care or services provided to that client.

3. • To meet professional and legal standards
• Documentation is a valuable method for demonstrating tha
• t, within the nurse-client relationship, the nurse has
• applied nursing knowledge, skills and judgment according to
professional standards. The nurse’s documentation
• may be used as evidence in legal proceedings such as
• lawsuits, coroners’ inquests, and disciplinary hearings
• through professional regulatory bodies. In a court of law, the
• client’s health record serves as the legal record of the
• care or service provided. Nursing care and the documenta
• tion of that care will be measured according to the
• standard of a reasonable and prudent nurse with similar education
and experience in a similar situation

4. Documentation is any printed or written record of
activities. In health care it should include:
1. Changes in the client's condition
2. The administration of tests, treatments,
procedures, and client education, with the results
of or client's response to them
3. The client's response to an intervention
4. The evaluation of expected outcomes
5. Complaints from client or family

5. • The methods of recording and reporting
information relevant to client care have
developed as a response to standards of practice,
legal and regulatory standards, institutional
standards and policies, and society's norms.
• Recording and reporting are the major ways
health care providers communicate. The client's
medical record is a legal document of all activities
regarding client care.

6. Purposes of Documentation (Ali
Abbas, 2011)
• The two primary purposes for documentation are
professional responsibility and accountability.
• The professional responsibility of all health care
practitioners, documentation provides evidence
of the practitioner's accountability to the client,
the institution, the profession, and society.
• Other purposes are communication, legal and
practice standards, education, reimbursement,
research, and auditing.

7. 1. Communication
• Documentation is a communication method that confirms the care
provided to the client and clearly outlines all important information
regarding the client.
• Thorough documentation provides:
• 1. Accurate data to plan care and ensure continuity of care.
• 2. Communication to health care team members involved in the client's
care.
• 3. Evidence of things done to or for the client, the client's response, and
revisions made in the plan of care.
• 4. Evidence of compliance with professional practice standards.
• 5. Evidence of compliance with accreditation criteria (e.g., those of the
Joint Commission).
• A resource for reimbursement, education, and research.
• 7. A written legal record to protect the client, institution, and practitioner.

8. 2. Practice and Legal Standards
• Thoroughly documenting care in the medical
record provides legal evidence that the care
provided meets approved standards of care .The
medical record is a legal document, and in a
lawsuit, it is the record that serves as the
description of exactly what happened to a client.
• In 80% to 85% of client care lawsuits, the
determining factor in providing proof of
significant events is the medical record.

9. • The legal aspects of documentation require:
• 1. Writing, legible and neat
• 2. Spelling and grammar, properly used
• 3. Authorized abbreviations
• 4. Time-sequenced, and factual descriptive
entries

10. 3. Education
• Health care students use the medical record as a tool
to learn about disease processes, medical and nursing
diagnoses, complications, and interventions. The
results of laboratory and diagnostic testing and physical
examinations provide valuable information about
specific diagnoses and interventions.
• Nursing students can enhance their critical-thinking
skills by examining and analyzing the records of the
health care team's plan of care, including the way the
care plan was developed, implemented, and evaluated.
All health care professionals including students must
maintain confidentiality when reading any client's
chart.

11. 4. Reimbursement
• The federal government requires peer review
organizations (PROs) to monitor and evaluate
the quality and appropriateness of care
provided. Medical records are reviewed for
documentation of intensity of services and
severity of illness

12. 5. Research
• The client's medical record is used by
researchers to determine whether a client
meets the research criteria for a study.
• Documentation can also indicate a need for
research. For example, if documentation
shows an increased rate of falls on certain
nursing units, researchers can look for and
study the variables associated with the
increased fall rate.

13. 6. Nursing Audit
• A nursing audit is a method of evaluating the quality of care provided to
clients. A nursing audit can focus on implementation of the nursing
process, on client outcomes, or on both in order to evaluate the quality of
care provided.
• The nursing audit is follow-up evaluation that not only evaluates the
quality of care of an individual client but also provides an evaluation of
overall care given in that health care facility. During a nursing audit, the
evaluators look for documentation of all five components of the nursing
process in the client records.
They examine the records for data related to:
• 1. Safety measures
• 2. Treatment interventions and client responses to them
• 3. Expected outcomes as basis for interventions
• 4. Client teaching
• 5. Discharge planning
• 6. Adequate staffing

14. GUIDELINES FOR DOCUMENTATION
1. Objective/Factual Documentation
• Registered nurses must document accurately,
completely, and objectively including any errors that
occurred. An objective description is the result of
direct observation andmeasurement.
• This means it should contain descriptive, objective
information about whatthe registered nurse sees,
hears, feels and smells. Registered nurses document
relevant information related to client care but do not
record opinions or assumptions. If something is not
documented, it could be challenged or assumed that it
was not done.

15. 2. Timeliness
• Documentation is enhanced when client
information is entered frequently into the client
• health-care record (Keatings & Smith, 2000).
Contemporaneous documentation, defined
• as the completion of the health-care record notes
as close to the time of care as possible,
• enhances the credibility and accuracy of health-
care records. Documentation of an
• intervention should never be completed before it
takes place.

16. 3. Use of Space
• Documentation must not have empty lines or
spaces, and the time when assessments and
• interventions were completed must be noted.
On forms or flow sheets every required
• space should be filled. “Not applicable” or
“N/A” should be noted rather than leaving a
• space blank (Baker, 2000).

17. 5. Follow-up
• Document any follow-up of assessments,
observations or interventions that have been
done, including whether a physician or other care
provider has been notified regarding the client.
• Failed attempts to reach a physician or other care
provider, the follow-up action taken, and the
client’s response to interventions should be
documented on the client’s health-care record.

18. 6. Correcting Errors
• To correct an error in a paper-based health-
care records system, one method that can be
used to appropriately make corrections is the
SLIDE rule (Baker, 2000). The SLIDE rule is
completed as follows: cross through the
word(s) with a single line, and insert your
initials, along with the date and time the
correction is made; then enter the correct
information/explanation

19. 7. Recording Medication Administration
• Document the administration of medications
immediately after its administration. This prevents
errors such as another RN administering medication
when the first dose was not recorded. The document
Medication Administration: Guidelines for Registered
Nurses (CARNA, 2005) outlines important aspects of
documentation of medication administration.
• The documentation of medications administered by
others is not acceptable, and RNs should only record
medications they have administered themselves

20. 8. Recording Assistance with Care
• In most circumstances, when a RN assists another
RN in providing care (e.g., when assisting another
RN to ambulate a patient or insert an IV), the RN
providing care documents the actions and the
client’s responses and notes that another care
provider assisted. It is not required to name the
person who assisted.
• In certain circumstances, as in a critical incident
such as a fall, it is important to record the names
of those individuals assisting.

21. 9. Designated Recorder in Emergency Situations
• In some emergency situations (e.g., during a
cardiac arrest), documentation may be done by a
designated recorder. When acting as a designated
recorder, the recorder identifies the persons
involved and the care they provided.
• The practice setting policies need to provide
guidance and support for how a designated
recorder should document and identify the forms
that are to be used.

22. 10. Clarification of Orders
• If an order is poorly written, never guess or
rely on group consensus to interpret that
order. Always call the writer for clarification.
• There is a high risk for error and potential for
an unsafe event to occur. A written record of
every telephone call should be maintained,
whether it is with another care provider for
clarification of orders, or with a client
following discharge from your facility or unit.

23. 11. Recording a Telephone Conversation with a Client
• When advice is given by telephone, the RN is
relying on the client’s own assessment of the
situation.
• The RN does not have the benefit of
examination and objective findings.
• The health-care record should include the
date (including year) and time of the call, the
nature of the call, the response by the RN, and
the follow-up recommendations (Baker, 2000).

24. 13. Client Education
• Documentation of educational interventions requires knowledge
and skills that are complex and comprehensive. Registered nurses
perform, on a daily basis, a broad scope and depth of client
education. Inadequate or incomplete documentation of client
education impedes communication among health-care providers
about what has been taught and diminishes the aspect of this
component of care provided by the registered nurse.
• When documenting and evaluating client education, it is important
to define the extent of the client’s understanding (London, as cited
in Bastable, 2003). For example, write: “Teaching was done related
to infection. Client accurately described the signs and symptoms of
infection and reported accurately that if any of these develop, he
would call his primary care provider.”

25. 14. Documenting an Incident in the Health-care Record
• When an incident occurs, pertinent data should be
documented on the health-care records of the client(s)
involved in the incident. However, the names of other
clients should not be recorded in another’s health-care
record. These names should be documented on an
report. The purposes of a health-care record and an
incident/occurrence report differ. The client health-
care record is a record of events directly related to the
client.
• Do not document “refer to incident/occurrence
report” in the client health-care record. The policy of
the practice setting should clearly describe the process
of completing an incident/occurrence report.

26. • An incident report provides a description of an unexpected or unusual event, for
example, a client fall, medication error or harm to clients, staff or visitors. Careful
documentation of incidents is important for continuous quality improvement,
learning from mistakes and managing risk, and in case of a complaint or legal
action. The following suggestions provide guidance on how to complete
documentation regarding an incident:
 • Be concise, accurate and objective.
 • Record what was seen, and describe the care provided, who else was involved
and
 the client’s (person’s) condition.
 • Do not try to guess or explain what happened (e.g., the RN should record that
side
 rails were not in place, but should not write that this was the reason the client fell
 out of bed).
 • Record the actions taken by other health-care providers at the time.
 • Do not blame individuals in the documentation.
 • Always record the full facts

27.  Jgn menghapus menggunakan tipe – x atau mencoret
tulisan yg salah ketika mencatat (perawat
menyembunyikan informasi/sengaja merusak!)
 Jgn menulis komentar yg bersifat kritik baik thd
px/tenaga ksht lain (dpt sbg bukti prilaku tdk profesional
dan askep tidak bermutu)
Tulis hal2 obyektif dari px & tindk yg dilakukan
 Koreksi kesalahan sesegera mungkin (kesalahan tulisan
dpt diikuti kesalahan tindakan!)
 Faktual, akurat, reliabel (jgn spekulasi/perkiraan!).
Hal penting dalam dokumentasi
(Nursalam, 2001)

28.  Akhir catatan jgn kosong (dpt diisi org lain). Buat
garis mendatar, tanda tangan
 Dapat dibaca, tulis dengan tinta, bahasa lugas (salah
baca = salah tafsir!)
 Catat klarifikasi jika bertanya ttg instruksi (diluar
wewenang dpt dituntut!)
 Tulis untk diri sendiri (tulisan pribadi = tanggung
jawab pribadi!)
 Hindari penulisan yg umum (jgn asal, tdk spesifik,
membingungkan!)
 Catat mulai dg waktu, akhiri dg TT (urutan harus
benar dan jangan menulis akhir dinas!)