Fundamentals of nursing documentation

DOCUMENTATION
2/23/2021
JONES H.M -MBA/DMS 1

 Documentation is any written or electronically
generated information about a client that
describes the care or service provided to that
client.
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 Documentation allows nurses and other care
providers to communicate about the care
provided.
 Documentation also promotes good nursing
care and supports nurses to meet
professional and legal standards.
 Through documentation, nurses
communicate their observations, decisions,
actions and outcomes of these actions for
clients.
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 Documentation is about giving an accurate
account of what occurred and when it
occurred. Nurses document information
pertaining to individual clients or groups of
clients.
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 To facilitate communication
 Through documentation, nurses
communicate to other nurses and care
providers their assessments about the status
of clients, nursing interventions that are
carried out and the results of these
interventions.
 Documentation of this information increases
the likelihood that the client will receive
consistent and informed care or service
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 Thorough and accurate documentation
decreases the potential for
miscommunication and errors.
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 To promote good nursing care
 Documentation encourages nurses to assess
client progress and determine which
interventions are effective and which are
ineffective, and identify and document
changes to the plan of care as needed.
 Documentation can be a valuable source of
data for making decisions about funding and
resource management as well as facilitating
nursing research,
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 all of which have the potential to improve the
quality of nursing practice and client care.
 Individual nurses can use outcome
information or information from a critical
incident to reflect on their practice and make
needed changes based on evidence.
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 To meet professional and legal standards
 Documentation is a valuable method for
demonstrating that, within the nurse-client
relationship, the nurse has applied nursing
knowledge, skills and judgment according to
professional standards.
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 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.
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Analysis of the Health Care
 The information of the files can assist the
professionals of the health system to point
out the needs of the particular nursing
institution, as well as the hospital’s services.
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Different hospitals have different protocols
On:
 how and who to document on the charts.
 Storage of records
 How often documentation should be done.
 How long the file should be kept in the ward
after patient is discharged or dies.
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 LEGAL DOCUMENTATION:
 Legal documentation refers to lawful written
information.
 The client’s record is a legal document and it
is acceptable in court as evidence. For
example, the positive laboratory results for
high vaginal swab would be used as evidence
of rape in the court of law especially in this
error of girl child sexual abuse by elderly
men.
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Compensation
 The documentation also assists the client in
obtaining compensation from the public and
private insurances. In order to obtain
 compensation, the file of the patient’s clinical
situation should have the right diagnosis.
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 COMMUNICATION
 The records serve as the vehicle by which
different health professionals who interact
with clients communicate with each other.
 For example, knocking off nurses give a
hand-over at the end of the shift to the
taking over nurses.
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 The knocking-off nurses explain to their
colleagues who are taking over the condition
of the clients in the wards, what type of care
and medication had been administered and
what had been advised to be done for the
client by the Doctor.
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 EDUCATION
 Students in health disciplines often use
medical records such as case notes as
educational tools.
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 CONTINUITY OF CARE
 It is after going through the past records and
reports that hospital staff refer patients to
other level of care for continuity of healthy
care. For example:
 The Healthy post personnel refer pregnant
women with a record of previous cesarean
section to the first level hospital for
continuity of care, that is caesarean section
procedure.
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 Accountability
 Records give an account of what the nurse
has been able to do the time they have been
on duty.
 With Records and reports available, it is easy
to find out the person responsible for an act
on the client because the records and reports
bear signatures of the caregiver.
 The caregiver is made responsible for his/her
action especially in times of mal practice or
negligence.
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 STATISTICS
 Statistics refers to a science that obtain facts
from figures.
 Statistical information from the client’s records
can help an agency anticipate and plan for
people’s future needs.
 For example, the number of admissions, or
births and types of illness can be obtained from
the records. This same data can help the hospital
to plan the type and quantity medicines to buy,
the number of beds to buy, the type of vaccines
to stock etc.
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 QUALITY ASSURANCE MONITORING
 The clients record is used to monitor the care
the client is receiving and the competence of
the people giving that care.
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 REFERENCE
 Records and reports could be used as
references especially in cases of an epidemic
like cholera, dysentery and sexually
transmitted diseases.
 Information from the previous records can be
used as a guide in management or to solve
the problem at hand. For example, the
disease notification records are kept and
used as references for future use.
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 PLANNING:
 Planning involves making preparations for
something in advance.
 The data obtained from the records and
reports enable the responsible people to plan
health services and to allocate resources.
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 Patient’s file which contains the case notes of
the hospital visit/stay.
 Graphic record which indicate body
temperature, pulse respiration, blood
pressure(BP),weight etc.
 Fluid balance sheet/record.
 Medication records/ Drug charts.
 Progress notes.
 Discharge records.
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 Progress notes are made based on a
practitioner client encounter.
 One of the most widely recommended
methods for documenting a particular client
encounter is the Subjective Objective
Assessment Plan (SOAP) format.
 This format is widely used in medical
practices for documenting client encounters.
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There are many advantages of using the SOAP
format and these include;
 encouraging comprehensive records.
 reducing unnecessary documentation.
 assisting in the organisation of the notes,
 saving time, and facilitating rapid and easy
retrieval of information from the record.
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 Subjective Data (S)
 Presenting complaint, including the severity
and duration of symptoms;
 Whether this is a new concern or an
ongoing/recurring problem;
 Changes in the client’s progress or health
status since the last visit;
 Past medical history of the client and their
family, where relevant to the presenting
 problem;
 Salient/important negative responses.
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 Objective Data (O)
 Relevant vital signs;
 Physical examination appropriate to the
presenting complaint;
 Positive physical findings;
 Significant negative physical findings as they
relate to the problem.
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 Assessment (A)
 Patient risk factors, if appropriate;
 Ongoing/recurring health concerns, if
appropriate;
 Review of medications, if appropriate;
 Review of laboratory and procedure results, if
available;
 Review of consultation reports, if available;
 Diagnosis, differential diagnosis, or problem
statement in order of probability and
reflective of the presenting complaint.
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 Plan (P)
 Discussion of treatment options;
 Tests or procedures ordered and explanation
of significant complications, if relevant;
 Consultation requests including the reason
for the referral, if relevant;
 New medications/remedies/supplements
ordered and/or medication repeats including
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 dosage, frequency, duration and an
explanation of potentially serious adverse
effects;
 Any other patient advice or client education
(e.g., diet or exercise instructions,
contraceptive advice);
 Follow-up and future considerations
 Specific concerns regarding the client
including client refusal to comply with your
suggestions.
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Written records should be-
 Factual, consistent and accurate
 Should be complete
 Well organised
 Written as soon as possible after an event has
occurred, providing current information on
the care & condition of the patient.
 Written clearly in such a manner that the text
can not be erased
 Accurately dated, timed and signed with the
signature printed alongside the first entry
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 Not include abbreviations, jargon,
meaningless phrases, irrelevant speculation
or offensive subjective statements
 Written wherever possible with the
involvement of the patient or carer and in
terms that the patient can understand
 Written in pen and not pencil
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 REPORTING
 Reporting is meant to communicate specific
information to a person or a group of people.
 A report is oral or written or computer based
communication intended to convey
information to others.
 A report whether oral or written should be
concise, including pertinent information.
 The purpose is to provide a permanent and
accurate record of relevant data.
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 A report is a legal document. It is required by
law to be kept for a period of five (5) years.
 The report must have correct spellings,
particularly on drugs and leave no doubt
concerning the information it contains. Only
universally accepted abbreviations must be
used.
 It should be signed by the person who has
written it.
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 CHANGE OF SHIFT REPORTS
 This is a report given to all nurses on the
next shift.
 Its purpose is to provide continuity of care
for clients by giving new care givers a quick
summary of client’s needs and details.
 The change of shift report should describe
each client’s health status and lets the staff
on the next shift know what care the client
will require.
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 A written report is made three times daily, in
the morning by the night staff, at midday by
morning staff and in the evening by the
afternoon staff.
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Handover reports
 The nurse taking over the ward must give her
undivided attention to her work, and this
procedure should be conducted in a quiet
manner without unnecessary interruptions.
 Any mistakes must be corrected and
clarifications made there and then.
 Report should be given from bed to bed
starting with the acutely ill patients.

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 All discharges and transfers and to where, if
relatives have been notified.
 All deaths including condition of the client
leading up to death time and doctor called if
relatives notified.
 All pre and post-operative clients (at least 48
hours condition on return from theatre,
medication ordered and if given or nay
treatment ordered.
 All pre-operative clients for special
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investigations state preoperative preparations
carried out etc.
 All clients in acute conditions.
 All clients on blood transfusion or infusion –
length of time when commenced, rate of flow
etc.
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 The important details to be included in the
ward report are:
 All admissions, name, age time of admission,
religion, next of kin, diagnosis if seen by a
doctor, any abnormalities and ordered
treatment and investigation to be clearly
stated.
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 All accurately ill clients e.g. recent head
injury, cerebral malaria, intestinal
obstruction, meningitis and acute cardiac
failure.
 Clients on special observations or procedures
like strong analgesics, 24 hours urine
collection etc
 NB: Observations of the above clients must
be carefully reported, what drugs given,
dosage and time, fluid balance stated.
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 The report particularly on very ill and newly
admitted should be detailed. No personal
comments should be written in the report. A
nurse reports what he/she observes not what
he/she feels about a client.
 Remember to sign the report.
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 ADMISSION REPORT
 On admission, a detailed ward report should
be written indicating
 name, age, sex,
 time of admission,
 date of admission,
 address,
 religion,
 next of kin,
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 where client is coming from
 diagnosis,
 bed number
 medication client is getting including dosage
and frequency
 observations done
 investigations done or to be done
 general condition of the client
 indicate whether the client has been seen by
the Dr or not
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 Progress report
 This is a report written on a client who is on the
ward. The nurse’s progress notes provide
information regarding the progress of a patient
towards the establishment of the desirable
results.
 It should indicate the progress the client is
making, how the client spent the day, any thing
special about the client eg had diarrhoea,
vomited, has a fever, etc.
 The report should also indicate the treatment the
client is getting. All observations done should be
indicated.
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 Incident Report
 This is the report of any event that is not
consistent with the routine operation of the
health care unit or care of the patient, e.g.
client falls, client given overdose, needle stick
injury, suicidal attempt, nurses fighting on
duty, nurse beaten on duty etc.
 incident report should have a detailed
account of how the event or incident
happened.
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 Transfer report
 This is the report which is written when a
client is transferred from one
unit/ward/hospital to another for specialised
care at a different level, e.g. a client being
transferred from intensive care unit to a
general ward. A transfer report can be given
on phone or in person. The following should
be included in the report;
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 Client’s name, age, and medical diagnosis
 Summary of the progress the client has made
since admission and the current health status
of the client
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 Death report
 This should include the detail of the client i.e.
name, age, date of admission, diagnosis and
management the client was receiving.
 It should include what has been done before
death, the treatment which was being given
and the resuscitations measures carried out.
 The time of death and time of certification
should be recorded.
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 Discharge report.
 This report should include all the particulars
of the client (name, age, address, diagnosis
etc), date of admission, and the medication.
Indicate what time the patient was discharged
what medication he/she will take home. Also
indicate if the client is still on the ward or has
gone with the relatives.
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 The report should also include the type of
discharge e.g. by the MO in charge or by
themselves (LAMA- Leave against medical
advice) where the client or relative sign
against advice of medical personnel.
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Health team members consult among
themselves to exchange ideas and
knowledge.
 We confer by consultation e.g. writing a
consultation form to a particular dept.
 Making referrals.
 Case conferences Drs come together and
discuss certain conditions e.g Hospital major
rounds.
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 Nurses major rounds.
 Handover time.
 Departmental meetings.
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Fundamentals of nursing documentation

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