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.
Documentation 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 accaount of the personal history, medical
history, result of diagnostic tests, findings in physical
examination, treatment and nursing care, progress note and
condition of discharge.
Charting- is a permanent, written and complete record of the
health history and sosiological information obtained from a
person admitted to a hospital by listening to him, looking at him
and treating him.
6. DOCUMENTATION SYSTEM
1. Source – Oriented Record
2. Problem – Oriented Medical Record (POMR)
3. Problem, Intervension, Evaluation. (PIE)
4. Focus Charting
5. Charting by Exception (CBE)
6. Computerized documentation and care
management.
7. 1) Source – Oriented record – is a narrative recording by each
member of the health care team on separate document.
2) Problem – Oriented Medical Record (POMR) are organized
around the client’s problem. It employs a structure, logical format,
which focuses on the client;s problem.
3) Problem, Intervension, Evaluation. (PIE) is an acronym for
problems, intervention and evaluation of nursing care this system
was to develop streamline documentation.
4) Focus Charting- highlight the client’s concerns, problems or
strengths. Is a documentation system using column to format data.
8. 5) Charting by Exception (CBE)- is a documentation in which only
abnormal or significant finding or exceptions to norms are recorded.
CBE use pre printed flow sheets to document the most aspects of
care.
6) Computerized documentation- Computer make care planning and
documentation relatively easy. Nurses use computers to store the
client database, add progress.
9. 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
10. 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
11. FORMS OF DOCUMENTATION
Kardexes – Is a concise methof 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
treatment, procedures and measurement of vital sign, procedures order such as
X-ray and lab test.
Flow Sheets – A simple form that gathers all important data regarding a patient
condition it includes graphic records, medication administration record.
Progress Notes – Is the notes made by nurses provided information about the
progress a clients is making towards Achieving desired outcome.
12. Discharge Summary
- Is completed when the patient being discharged and refered to
home. It includes Client instruction about medication, diet,
food drug interaction, etc.
13. Nurse’s Responsibilities In Documenttation
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
14. CONCLUSION
Documentation is the act of recording clients
status and care in the written form. Clients
records are legal documents that provide
evidence of a client Care.
