MICRO TEACHING ON DOCUMENTATION OF NURSING PROCESS 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. INTRODUCTION 3. DEFINITION 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. • To facilitate communication • To promote good nursing care • To meet professional and legal standards PURPOSE FOR DOCUMENTATION 5. Benefits of the Nursing Notes Nursing documentation provides: • An account of judgment • Critical thinking used in the nursing process. 6. Cont… Accurate, timely documentation reflects care provided: • Professional, legislative, & agency standards • Enhance nursing care • Facilitate communication b/w nurses & other health care providers. 7. 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. 8. GUIDELINES FOR DOCUMENTATION • Factual • Accurate • Complete • Current • Organized 9. CONSEQUENCES OF INADEQUATE DOCUMENTATION • Fragmented care • Repetition of tasks • Delayed therapy • Omitted therapy • Delayed recovery 10. Refrences •DUGas, B., Esson, L. & Ronaldson, S.(1999). Nursing Foundation: A Canadian Perspective. Scarborough: Prentice Hall Canada, P. 480

1. DOCUMENTATION OF
NURSING PROCESSES
Presented by:- Harsh Rastogi
M.Sc. Nursing I year
K.G.M.U. I.O.N.

2. 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.
INTRODUCTION

3. DEFINITION
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. • To facilitate communication
• To promote good nursing care
• To meet professional and legal
standards
PURPOSE FOR DOCUMENTATION

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

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

7. 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.

8. GUIDELINES FOR DOCUMENTATION
• Factual
• Accurate
• Complete
• Current
• Organized

9. CONSEQUENCES OF
INADEQUATE DOCUMENTATION
• Fragmented care
• Repetition of tasks
• Delayed therapy
• Omitted therapy
• Delayed recovery

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