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1. DOCUMENTATION
BY MARYJOY

2. TYPES
 Patient notes.
 Reflective journalism.
 Clinical experience log.
 Skills check.

3. PATIENT NOTES.
TYPES OF PATIENT DOCUMENTATION.
 Kardex.
 Observation sheets e.g. vital signs, fluid
charts.
 Laboratory results.
 Admission notes.

4. GUIDELINES FOR DOCUMENTATION.
 Document legibly.
 Use of ink for permanency.
 No erasing or use of white out. Instead, draw a single straight
line through the error, sign your name or initials then record
correctly.
 Don’t leave blank spaces: draw a straight line through the
space.
 Use correct grammar and spelling.
 Use of standard terminology e.g. abbreviations, symbols and
terms.
 Factual- descriptive and objective. No use of terms like fair,
good, seems, calm, stable.
 Accurate e.g. intake 200ml vs. adequate fluids.
 Complete e.g. dosage, route, frequency.

5. GRADING.
 Clinical experiences- must obtain 70% failure
to which the rotation is repeated.
 Case study.
 Skills check.
 Clinical experiences log.
 Punctuality- if late the hours must be
replaced/ paid.