The document outlines the importance and procedures for clinical documentation in nursing, detailing its definition, purpose, and applicable items. It emphasizes the responsibilities of nurses in maintaining accurate patient records, including assessment, care plans, and progress notes, while ensuring compliance with legal and administrative standards. Resources referenced include the Canadian Nurses Association's Code of Ethics for Registered Nurses.

1. PREPARED BY
SUGUNA
NS

2. CONTENTS
1.DEFINITION
2.RECORDS
3.REPORT
4. PURPOSE OF RECORDING AND REPORTING
5.APPLICABLE ITEMS
6.PROCEDURE
7.RESOURCES

3. DEFINITION OF DOCUMENTAION
It is the process of
communicating in written
form about essential facts
for the maintenance of
continuous history

4. RECORDS
It is a clinical
scientific
administrative
legal document
related to the
care given to
individual,famil
y community.

5. REPORT
It is an
exchange of
information
verbally or
written
form between
nurse of
health team.

6. PURPOSE OF RECORDING AND REPORTING
I. COMMUNICATION
II. EDUCATION
III. ASSESSMENT
IV. RESEARCH
V. AUDITING AND
MONITORING
VI. LEGAL ADMINISTRATIVE

7. APPLICABLE ITEMS
a) Case file
b) Nursing initial assessment ,re assessment ,nursing care plan and RN handover check
book
c) Nurses progress notes
d) Departmental registers
e) Clinical check lists

8. PROCEDURE
I. Nurses are the custodian of all the patient and
departmental documents.
II. Charge nurse /shift in charge nurses are
responsible for departmental records and
administrative data
III. RN is responsible to close file with relevant
data.
IV. Ensure that nursing clinical documentation
includes:
 All aspects of the nursing process such as

9. PROCEDURE
Clear and concise statement of patient status ( physical ,
psychological and spiritual)
Details of clinical assessment and monitoring
The care/service provided ( interventions, advocacy
counselling, consultation and teaching )
Evaluation of outcomes, including the patient’s response
and further plan
Discharge plan

10. PROCEDURE
Plan of care
 it should be clear ,concise and accurate as per the
patient condition / needs
Details of risk assessment ,admission. Transfer ( in
and out )and discharge information ,patient and family
education ,incident reports ,medication administration
,verbal orders and telephone orders.
I. Ensure that the nurses progress note is
 Clear, concise.unbiased and accurate

11. PROCEDUE
Legible with correct spellings.
Without blank space , abbrevations, symbols and acronyms
Avoid generalized statements and no use of whitener
I. If any mistake /error : cross through the words with a single line above the
line write as mistake /error and write name and signature of the nurse along
with the date and time
II. For any change /additions in the documents , obtain a formal permission
from the hospital management
III. Nurse should document the details on timely ,chronologically and
frequently

12. RESOURSES
Canadian nurses association
(2018) code of ethics for
registered nurses.
Ottawa,ON,Author.

13. THANK YOU