Useful information about Nursing documentation for all novice nurses and nursing students according to international standard

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IS 2nd TO ASK, PRIOR PERMISSION IS MANDATORY
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jzk_yz@hotmail.com

3. THE TEAM OF CCU present
One day workshop on
NURSING DOCUMENTATION

4. INTRODUCTION TO
DOCUMENTATION
Jehanzeb khan Yousafzai
RN, MSc N, Post RN, BScN, DiP. Card,
Nursing Instructor
College of Nursing, SZABMU,PIMS,
Islamabad

5. OBJECTIVES
At the end of the session you will be able to:
• Define the documentation
• Explain the purposes, uses and the principles of
documentation
• Classify the documentation in various systems / categories
• Define the nursing process (Nursing Care Plan NCP)
• Understand the parts of NCP
• Know the documentation of various parts of NCP
• Develop a nursing care plan
• Know the references

6. DOCUMENTATION
• Any printed or written record of activities.
• Recording and reporting are the major ways
health care providers communicate.
• The client’s medical record is a legal
document of all activities regarding client
care.

7. PURPOSES OF
DOCUMENTATION
• Communication
• Practice and legal standards
• Education
• Research
• Nursing audit

8. COMMUNICATION
• Documentation confirms the care
provided to the client and clearly
outlines/summarizes all important
information regarding the client.

9. PRACTICE AND
LEGAL STANDARDS
The legal aspects of documentation
require:
• Writing readable and neat
• Spelling and grammar properly used
• Authorized abbreviations used
• Time-sequenced factual and descriptive
entries

10. PRACTICE
STANDARDS INCLUDE:
• Nursing Practice according to stat’s Act
• Joint Commission on Accreditation of Healthcare
Organizations (JCAHO)
[if apply]
• Confidentiality
• Informed consent
• Advance Directives

11. Advance Directives
• a living will which gives durable power of
attorney to a surrogate (Substitute)
decision-maker, remaining in effect during
the incompetency of the person making it.

12. EDUCATION
• Health care students use medical record as
tool to learn about disease processes,
nursing diagnoses, complications and
interventions.
• Students can enhance critical-thinking skills
by examining the records and following
health care team’s plan of care.

13. RESEARCH
• The client’s medical record is used by
researchers to determine whether a
client meets the research criteria for a
study.
• Documentation can also indicate a need
for research.

14. NURSING AUDIT
• Method of evaluating the quality of care
• Includes:
• Safety measures
• Treatment interventions and responses
• Expected outcomes
• Client teaching
• Discharge planning
• Adequate staffing

15. PRINCIPLES OF EFFECTIVE
DOCUMENTATION
1. Document accurately, completely, and
objectively, including any errors.
2. Note date and time.
3. Use appropriate forms.
4. Identify the client.
5. Write in ink.
6. Use standard abbreviations.

16. PRINCIPLES OF EFFECTIVE
DOCUMENTATION (continued)
7. Spell correctly.
8. Write legibly.
9. Correct errors properly.
10.Write on every line.
11.Sign each entry.

17. SYSTEMS OF
DOCUMENTATION
• Narrative charting
• Source-oriented
charting
• Problem-oriented
charting
• PIE charting
• Focus charting
• Charting by
exception
• Computerized
documentation
• Critical pathways

18. NARRATIVE CHARTING
• Traditional method of nursing
documentation.
• Chronologic account in paragraphs
describing client status, interventions and
treatments, and client’s response.
• The most flexible system.
• Usable in any clinical setting.

19. SOURCE-ORIENTED
CHARTING

20. PROBLEM-ORIENTED
CHARTING
• SOAP, SOAPI, AND SOAPIER
S: subjective data (How does the client feel?)
O: objective data (results of the physical exam,
relevant vital signs)
A: assessment data (what is the client’s status?)
P: plan (Expectation about outcome )

21. I: implementation (what did the nurse do?)
E: evaluation (what did the client get
following the intervention?)
R: revision ( what changes are
needed to the care plan?)

22. • S = subjective data (e.g., how does the client
feel?)
• O = objective data (e.g., results of the physical
exam, relevant vital signs)
• A = assessment (what is the client’s status?)
• P = plan (e.g., does the plan stay the same? is a
change needed?)

23. • I = intervention (e.g., what occurred? what did the nurse
do?)
• E = evaluation (e.g., what is the client outcome following
the intervention?)
• R = revision (e.g., what changes are needed to the care
plan?)

24. PIE CHARTING

25. FOCUS CHARTING
• System using a column format to chart
Data, Action, and Response (DAR).

26. CHARTING BY EXCEPTION
• Only significant findings (exceptions) are
documented in a narrative form.
• Presumes that unless documented otherwise, all
standardized protocols have been met and no
further documentation is needed.

27. COMPUTERIZED
DOCUMENTATION
• Reduces time taken, increases accuracy.
• Increases legibility.
• Stores, retrieves information quickly.
• Improves communication among health care
departments.
• Confidentiality and costs can be problems.

28. CRITICAL PATHWAY
• Also known as Care Maps.
• Comprehensive pre-printed standard plan
reflecting ideal course of treatment for diagnosis
or procedure, especially with relatively predictable
outcomes.
• Additional forms are needed to complement the
pathway.

30. NURSE’S PROGRESS NOTES
• Document client’s condition, problems,
complaints, interventions, and client’s
response to interventions.
• Include, vital signs records, flow sheets,
and intake and output forms.

31. DISCHARGE SUMMARY
• Client status on admission and discharge
• Brief summary of the client’s care
• Intervention and education outcomes
• Resolved and unresolved problems
• Client instructions about medications,
diet, food-drug interactions, activity,
treatments, follow-up, and other needs

32. INFORMATION
FOR SHIFT REPORT
• Name, room and bed,
age, gender
• Physician, admission
date, and diagnosis
• Diagnostic tests or
treatments performed
in past 24 hours
(results if ready)
• General status, any
significant change
• New or changed
physician’s orders
• IV fluid amounts,
last medication
• Concerns about
client

33. TELEPHONE ORDERS
• Date and time
• Order as given by the physician
• Signature beginning with t.o. (telephone
order)
• Physician’s name
• Nurse’s signature
• Physician must countersign

34. The Nursing Process
Jehanzeb khan Yousafzai
RN, MSc N, Post RN, BScN, DiP Crad,
Nursing Instructor
College of Nursing, SZABMU,PIMS,
Islamabad

35. Introduction
• Nursing is an art of applying scientific
principles in a humanitarian way to care of
people
• The nursing process serves as the
organizational framework for the practice of
nursing.

36. Martha Rogers Nurse Theorist
• “When an apple is cut, others see
seeds in the apple. We, as nurses,
see apples in the seeds.”

37. The Nursing Process
• An organizational framework for the practice
of nursing
• Orderly, systematic
• Central to all nursing care
• include all steps taken by the nurse in
caring for a patient

38. Definition of the Nursing
Process
• An organized sequence of problem-solving
steps used to identify and to manage the
health problems of clients
• It is accepted for clinical practice
established by the American Nurses
Association

39. Benefits of Nursing Process
• Provides an orderly & systematic method for
planning & providing care
• Enhances nursing efficiency by standardizing
nursing practice
• Facilitates documentation of care
• Provides a unity of language for the nursing
profession
• Stresses the independent function of nurses
• Increases care quality through the use of
deliberate actions

40. Characteristics of the
Nursing Process
• Within the legal scope of nursing
• Based on knowledge-requiring critical
thinking
• Planned-organized and systematic
• Client-centered
• Goal-directed
• Prioritized
• Dynamic (with continuity)

41. Being Accountable
• Using critical thinking before taking actions
• Being responsible for your actions
• Entering the professional role
• Working at the level of your peers
• Using the nursing process

42. What Are Your Responsibilities?
• Recognize health problems.
• Anticipate complications.
• Initiate actions to ensure appropriate
and timely treatment.
Begin to think CRITICALLY !!!!!!

43. Critical Thinking
• Critical thinking in nursing is an essential
component of professional accountability
and quality nursing care.
• Critical thinking is careful, deliberate, and
goal directed.

44. Lets Get Started :
• Arrange seating
• Allow adequate time
• Nurse introduces self
• Identifies purpose of interview
• Ensure environment is favorable
• Ensure confidentiality of information
• Provide for patient needs before starting
• Collects background info from previous charts

45. Components of nursing process

46. The nursing process consists of five dynamic and
interrelated phases:
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation.

47. Assessment
Diagnosis
Planning
Implementation
Evaluation

48. REMEMBER
• SOAP, SOAPI, AND SOAPIER

50. Definition of Assessment
• “Continuous and systematic collection,
validation, and communication of client
data .”
(Harrington, 1996)

51. Assessment
Is the systematic and continuous:
• collection
• organization
• validation
• documentation of data.

52. Assessment of Well-Being
• According to the World Health
Organization well-being is in the following
domains:
• Emotional
• Physical
• Social
• Spiritual

53. Assessment is part of each activity the nurse does
for and with the patient. The purposes is
1.To validate a diagnosis
2.To provide basis for effective nursing care.
3.It helps in effective decision making
4.Basis for accurate diagnosis
5.It promote holistic nursing care
6.To provide effective and inventive nursing
care
7.To collect data for nursing research
8.To evaluation of nursing care
PURPOSE

54. Assessment process:
Is a systematic method by which nursing :plans
and provides care for patients.
This involves a problem-solving approach that
enables the nurse to identify patient problems
and potential at-risk needs (problems) and to
plan, deliver, and evaluate nursing care in an
orderly, scientific manner.

55. The Process
Assessment
Collect data Organize data Validate data
Documenting
data

56. The Process
• The nurse gathers information to identify the
health status of the patient.
• Assessments are made initially and
continuously throughout patient care.
• The remaining phases of the nursing
process depend on the validity and
completeness of the initial data collection.

57. Assessment Dimensions
• C- Characteristic
• O- Onset
• L- Location
• D- Duration
• E- Exaggerating factors
• R- Relieving factors
• R- Radiation to
• A- Associated symptoms

58. Fluids should be
assessed for
• C- Color
• O- Odor
• C- Consistency
• A- Appearance

59. Essential pre-
assessment activities
• Choose a framework for assessment and
documentation
• Gordon’s functional health patterns
• Control the environment
• Work on assessment skills
• Observation
• Interviewing
• Physical exam
• Intuitions

60. Verifying Data
• Essential in critical thinking!!!!!
• Measurable data
• Double check personal observations
• Double check equipment
• Check with experts and team members
• Compare objective and subjective data
• Clarify statements

61. Types of Data
• Subjective: facts presented by the client that
show his/her perception
• Objective: facts that are observable and
measurable by the nurse, involves use of
the senses
• Seeing
• Hearing
• Smelling
• Touching

62. Types of Sources of Data
• Primary: from the client, considered the most
reliable if the client is deemed a good historian
• Nursing judgment
• Secondary: significant others, the medical or
health record, lab tests, diagnostic
procedures, meds, past medical HX, other
health team members, and literature review
• Data needs to be validated

63. Sources
• Client
• Other individuals
• Previous records
• Consultations
• Diagnostics studies
• Relevant literature

64. Documentation Of
subjective data
• Use patient’s own words in subjective data – enclose
in “ ___” (quotation marks)
• Avoid generalizations – be specific
• Don’t make summative statements – describe - e.g.
patient is being irritating
it should be the patient resists instruction or patient
states “Don’t talk to me, I don’t care about that”

65. Organization of Data
• Need to use an organized assessment
framework to help cluster assessment data
(cues)into meaningful groups
Gordon’s Functional Health
Patterns

66. Measurement Criteria
for ANA
Assessment: The nurse collects client
health data
• Data collection involves client, significant
others, and healthcare providers when
appropriate
• The priority of data collection activities is
determined by the client’s immediate
condition or needs

67. • relevant data are collected using appropriate
assessment techniques and instruments
• Relevant data are documented in a retrievable
form
• The data collection process is systematic and
ongoing

68. Things that impair
communication:
• Presenting quick solutions
• Unwarranted cheerfulness (happiness)
• False reassurance
• Giving advice
• Changing the subject

69. NURSING
DIAGNOSIS

70. MEDICAL DIAGNOSIS
• Clients have both nursing and medical
diagnoses.
• A medical diagnosis is a clinical judgment by
the physician that identifies or determines a
specific disease, condition, or pathological
state.

71. What is NANDA?
• NANDA-I (North American Nursing Diagnosis
Association International) originated from a
Nursing Conference in St. Louis, MO, in 1973. This
conference had as a topic: "Classification of
Nursing Diagnosis". In 1982, the North American
Nursing Diagnosis Association was formed, and it
became NANDA-I in 2002.

72. NURSING DIAGNOSIS
• Second step in the nursing process.
• Clinical judgment about individual, family, or
community response to actual or potential
health problems/life processes.
• Provides the basis for client care through
the remaining steps.

73. NURSING DIAGNOSIS
• Sort, cluster, analyze information
• Identify potential problems and strengths
• Prioritize the problems
• Not a medical diagnosis
• Risk of infection related to compromised
nutrition
• Potential for effective breastfeeding related to
knowledge level and support system

74. Maslow's Hierarchy of Needs

75. The original hierarchy of needs
five-stage model includes:
1. Biological and Physiological needs - air, food, drink,
shelter, warmth, sex, sleep.
2. Safety needs - protection from elements, security,
order, law, limits, stability, freedom from fear.
3. Social Needs - belongingness, affection and love, -
from work group, family, friends, romantic
relationships.

76. 4. Esteem needs - achievement, mastery,
independence, status, dominance, prestige, self-
respect, respect from others.
5. Self-Actualization needs - realizing personal
potential, self-fulfillment, seeking personal growth
and peak experiences.

77. PARTS OF
NURSING DIAGNOSIS
• Part one– Problem statement or diagnostic
label describing the client’s response to actual
or risk health problem or wellness condition.
• Part two– Etiology or the related cause or
contributor to the problem.
• Linked by the term related to (r/t).

78. THREE-PART
NURSING DIAGNOSIS
• Part one–diagnostic label.
• Part two–etiology.
• Part three–defining characteristics, or signs
and symptoms, subjective and objective data,
or clinical manifestations.
• Third part linked to the first two by the term as
evidenced by (AEB).

79. TYPES OF
NURSING DIAGNOSES
• Actual nursing diagnosis–indicates that
problem exists.
• Risk nursing diagnosis–indicates that specific
risk factors are present.
• Wellness nursing diagnosis–client’s statement
of desire to attain a higher level of wellness in
some area of function.

80. PLANNING AND
OUTCOME IDENTIFICATION
• Third step of the nursing process.
• Includes establishing guidelines for the
proposed course of nursing action and
developing the client’s plan of care.

81. Expected outcome/ Planning
• R- Realistic
• U- Understandable
• M- Measurable
• B- Behavioral
• A- Achievable

82. Planning should be SMART
• S- Systematic
• M- Measurable
• A- Achievable
• R- Realistic
• T- Time bond

83. PLANNING PHASES
• Initial planning–developing a preliminary
plan of care.
• Ongoing planning–updating the client’s
plan of care.
• Discharge planning–anticipating and
planning for the client’s needs after
discharge.

84. PLANNING INVOLVES …
• Prioritizing the nursing diagnoses.
• Identifying and writing client-centered
long- and short-term goals and outcomes.
• Identifying specific nursing interventions.
• Recording the entire nursing care plan in
the client’s record.

85. Components of Outcomes
• Subject: who is the person expected to
achieve the outcome?
• Verb: what actions must the person take to
achieve the outcome?
• Condition: under what circumstances is the
person to perform the actions?
• Performance criteria: how well is the
person to perform the actions?
• Target time: by when is the person
expected to be able to perform the actions?

86. Steps for deriving outcomes
from Nursing Diagnosis
• Look at the first clause of the nursing dx and
restate in a statement that describes
improvement, control or absence of the
problem.
 Risk for infection r/t surgical procedure.
 The client will demonstrate no signs or
symptoms of infection till the end of my duty

87. General Guidelines for
Setting Priorities
1. Take care of immediate life-threatening
issues.
2. Safety issues.
3. Patient-identified issues.
4. Nurse-identified priorities based on the
overall picture, the patient as a
whole person, and availability
of time and resources.

88. Nurse Identified Priorities
• Composite of all patient’s strengths and
health concerns.
• Moral and ethical issues.
• Time, resources, and setting.
• Hierarchy of needs.
• Interdisciplinary planning.

89. Identifying Client-centered
Outcomes
• State what the patient will do or experience at
the completion of care.
• Give direction to the patient’s overall care.
• Patient behaviors not nurse behaviors!!
 “The patient will…”

90. Short-Term Goals
• Outcomes achievable in a few days or 1
week
• Developed from the problem portion of the
diagnostic statement
• Client-centered
• Measurable
• Realistic
• Accompanied by a target date

91. Long-Term Goals
• Desirable outcomes that take weeks or
months to accomplish for client’s with
chronic health problems

92. Nursing Interventions
• Road maps directing the best ways to
provide nursing care.
• Evidence based nursing.
1. Monitor health status.
2. Minimize risks.
3. Resolve or control a problem.
4. Assist with ADLs.
5. Promote optimum health and
independence.

93. Selecting an intervention
• The nurse selects strategies based on the
knowledge that certain nursing actions
produce desired effects.
• Nursing interventions must be safe, within
the legal scope of nursing practice, and
compatible with medical orders.

94. CATEGORIES OF
NURSING INTERVENTIONS
• Independent–initiated by the nurse and
do not require an order.
• Interdependent–implemented in a collaborative
manner by nurse in conjunction with other health
care professionals.
• Dependent–requires an order.

95. Interventions
• Direct interventions:
• Actions performed through interaction
with clients.
• Indirect interventions:
• Actions performed away from the client, on
behalf of a client or group of clients.

96. Evaluation
• Ongoing part of the nursing process
• Determining the status of the goals and
outcomes of care
• Monitoring the patient’s response to drug
therapy
• The way nurses determine whether a client
has reached a goal.
• It is the analysis of the client’s response,
evaluation helps to determine the
effectiveness of nursing care.

97. Evaluation
1. Determining outcome achievement
2. Identifying the variables affecting outcome
achievement
3. Deciding whether to continue, modify, or
terminate the plan

98. Determining Outcome
Achievement
• Must be aware of outcomes set for the client.
• Must be sure patient is ready for evaluation.
• Is patient able to meet outcome criteria?
• Is it:
Completely met?
Partially met?
Not met at all?
• Record in progress in notes.
• Update care plan.

99. Identifying Variable Affecting
Outcome AchievemAent
• Maintain individuality of care plan:
1. Is the plan realistic for the client?
2. Is the plan appropriate at the time for this
particular client?
3. Were changes made in the plan when
needed?
4. How does the client feel about the plan?

100. Predict, Prevent, and Manage
• Focus on early intervention
• Based on research
• Predict and anticipate problems
• Look for risk factors

101. Refrences;
• Andrea Ackermann, Mount St. Mary College, Critical-
thinking-the-nursing-process 2001.
• http://www.umanitoba.ca/nursing/courses/128,(2005)
• Sara-jo Wiscombe, Nursing Process ,Wallace Community
College ,May 22,2001.
• Tucker C, MODULE A INTRODUCTION TO NURSING
Process, August 21, 2002 .