This document discusses nursing documentation policies and procedures. It covers the purposes of documentation which are to serve as communication between healthcare members, provide a permanent legal record, and ensure continuity of care. It also discusses different types of documentation like the problem-oriented charting format and flowsheets. The document provides guidance on documenting verbal/telephone orders, panic lab results, and handovers. It emphasizes adhering to hospital policies and procedures to maintain patient and staff safety.

1. Prepared by: GIANNE T. GREGORIO

2. DOCUMENTATION
 Purpose
 DAR Documentation
VERBAL AND TELEPHONE ORDER
PANIC RESULTS REPORT AND HANDOVER
RECOMMENDATIONS
REFERENCES

3. At the end of the lecture, Nurses will be able to:
Familiarize and understand the Nursing policies discussed.
Strictly adhere to hospital policy and procedure.
Implement measures to maintain patient and staff safety at
all times.

5. To serve as communication between
healthcare members involved in
client’s care.
To provide a permanent and legal
record to protect client, institution and
practitioner.
To ENSURE CONTINUITY OF CARE.

6. Serves as a permanent record of patient information
and care. It is a written record of a patient’s progress
and nursing care provided.
A type of documentation that is in problem-oriented
charting format, routine nursing task and assessment
data are documented in the flowsheet.

7. DATA – These are subjective or objective information
that supports the stated/main problem or describes
observation at the time of a significant event.
ACTION – Refers to past, present or future nursing
actions based on the assessment/evaluation of the
patient’s condition. This action also includes evaluation
of the present care plan and any changes and
modifications required.
RESPONSE – Describes the patient’s progress and
response to therapy. It is the discussion of outcomes
(goals) in the patient’s plan for specific problem

10. An order made during
emergency or life-
threatening condition
Order must be written in
the order sheet after the
disaster.

11.  Order made by doctor who is physically unable to write and
order that need immediate intervention.
 Will only be accepted by nurse when immediate patient care or
intervention is required.
 Narcotic & high alert medication is NOT ALLOWED
 MUST be signed within 24 hours
 1 nurse will read back and write at the same time, must be
written in order sheet.
 Limit TO communication of prescription or medication orders to
urgent situation in which immediate written or electronic
communication is not feasible.
03/07/19 at 2000H: T.O. by Dr. Ibrahim Bargash
Inj. Diclofenac Sodium 50 mg intramuscular STAT
Dr. Ibrahim Bargash/Gianne Gregorio

13.  A result that is outside the normal range and may
indicate high risk life threatening condition.
HOW TO DOCUMENT PANIC VALUE?
Example:
Date/Time: D – Received call from hematology department as
per brother Ali, Pt potassium level is 2.
Time: A – Informed Dr. Hatem regarding the result of patient’s
potassium level.

14. Strictly adhere to hospital and nursing Policy and
Procedures.
Proper assessment for proper intervention and
documentation.
Proper patient monitoring and management.

15.  QM 002 V05
 Nursing service policy and procedure NR 03 2 – V03