This document provides a comprehensive overview of nursing documentation processes, emphasizing the importance of accurate assessment, interventions, and outcomes for clients. It outlines the purpose, benefits, and principles of nursing notes, stressing the need for effective communication and adherence to legal standards. Furthermore, it highlights the consequences of inadequate documentation, including fragmented care and delays in therapy.

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