Documentation in nursing serves several key purposes: to communicate information about patient care, support legal requirements, and enable quality assurance. There are various types of documentation including recording and charting. Common documentation systems are problem-oriented medical records, problem-intervention-evaluation, and computerized documentation. Nurses must follow best practices for documentation like using objective language and maintaining patient privacy, while correcting errors and documenting all teaching.

1. FON ASSIGNMENT
TOPIC-DOCUMENTATION IN NURSING

2. GENERAL OBJECTIVE
 Define documentation
 Enlist Purpose of documentation
 Types of documentation
 Explain Documentation System
 Do And Don’t
 Discuss Forms Of Documentation
 Nurse’s Responsibilities In Documentation

3. Definition
Documentation-Documentation is the act of
recording client’s status and care in a written
form.
 Doucmentation is any printed or written
record of activities.

4. Purpose Of Documentation
 Communication
 Education
 Legal Document
 Quality Assurance
 Research
 Nursing Audit
 Health Care Analysis

5. Types Of Documentation
1. Recording
2. Charting
 Recording- Is a brief account of the personal history,
medical history, results of diagnostic tests, findings in
physical examination, treatment and nursing care,
Progress notes and condition on discharge.

6.  Charting- Is a permanemt, written and complete record
of the health history and sociological information obtained
from a person admitted to a hospital by listening to him,
looking at him and treating him.

7. Documentation System
1. Source-Oriented Record.
2. Problem-Oriented Medical Record (POMR).
3. Problem, Itervention, Evaluation (PIE).
4. Focus Charting.
5. Charting by exception (CBE).
6. Computerized documentation and care management.

8. • Source-Oriented record- Source-oriented is a narrative
Recording by each member of the health care team on
separate documents.
• Problem-oriented Medical Record- (POMR) are
organized
around the client’s problem. It employs a structured, logical
format, Which focuses on the client’s problem.

9. • Problem, Intervention, Evaluation- PIE is an
acronym for problems,intervention and
evaluation of nursing care this system was
to develop streamline documentation.
• Focus Charting- highlights the client’s concerns,
problems or strengths. Is a documentation
System using column to format data.

10. • Charting by exception (CBE)- Is a documentation in which only
abnormal or significant finding or exceptions to norms are
recorded. CBE uses pre-printed flow sheets to document the most
aspects of care.
• Computerized documentation- Computers make care planning and
Documentation relatively easy. Nurses use computers to store the
client database, add progress.

11. Do’s and Do Not’s
 Do’s
 Use objective, specific and factual description
 Correct the charting errors
 Chart all teaching
 Review your notes
 Do support medical necessity

12. Do Not's
• Leave blank space for a colleague to chart later
• Chart in advance of the event
• Use vague terms
• Chart for someone else
• Use patient or client as it is in the chart
• Alter a record, even if requested by a physician
• Record assumption or a word reflecting bias

13. Forms Of Documentation
• Kardexes- Is a concise method of organizing and recording
data about a client, making information quickly accessible to
all health professional. It contains- Client information, list of
medical diagnosis on priority, allergies, list of daily treatments,
procedures and measurement of vital signs, procedure order
Such as X-ray and lab tests.

14. • Flow Sheets- A simple form that gathers all important
data regarding a patient’s condition it includes graphic
records, medication administration record, etc.
• Progress Notes- Is the notes made by nurses provided
information about the progress a client is making
towards Achieving desired outcome.

15. • Discharge Summary- Is completed when the patient
is being discharged and refered to home. It includes:
Client instructions about medication, diet, food-drug
Interaction, etc.

16. Nurse’s Responsibilities In Documentation
• Should keep under safe custody of nurses.
• No individual sheet should be separated.
• Not accessible to patients and visitors.
• Strangers is not permitted to read records.
• Errors in nursing charting must be corrected
Promptely in a manner that leaves no doubts
About the facts.

17. Summary
Today we have discussed about
• Types of documentation
• System of documentation
• Do and Do not’s
• Forms of documentation
• Nurse‘s responsibilities in documentation

18. Conclusion
Documentation is the act of recording client’s status
and care in the written form. Client records are legal
documents that provide evidence of a client’s Care.
Examples of documentation system include PIE,
focus charting, charting by exception (CBE),
computerized documentation and case management.

19. Questions
1. Define documentation.
2. Enlist the purposes of Documentation.
3. What are the types of documentation?
4. Explain uses of documentation systems.
5. What are the nurse’s responsibilities in documentation

20. Reference
• Nursing Foundation Jaypee.
Author- BT basavanthappa
• Nursing Foundation- 3rd edition
Author- I Clement
• Jems.com