nursing

1. Documentation
In nursing

2. OUT LINE
1 Introduction
2 Definition of documentation
3 Purpose of documentation
4Principles of documentation
5-Types of documentation
6 Methodes of documentation
7 Formes of recording data
8Consequences of inadequate documentation
9-Definition of reporting
10-Purpose of reporting
11- Criteria of good report
12-Types of report
13 Importance of record and report
14Definition of Electronic documentation
15-Guide lines of electronic documentation
16 advantage and disadvantage of electronic documentation
17 Role of nurse manager during documentation

3. Introduction
* Documentation as Communication Reporting
and recording are the major communication
techniques used by health care providers.
* Nursing documentation is a vital component of
safe, ethical and effective nursing practice,
regardless of the context of practice or whether
the documentation is paper-based or electronic.

4. Definition of documentation:
Any written or electronically generated
information about a client that describes the
care or service provided to that client.
The administration of tests, procedures,
treatments, and client education.

5. Purpose of health care documentation
1. Professional Responsibility andAccountability
2. To facilitate communication
3. To promote good nursing care
4. To meet professional and legal standards
5. Education
6. Research
7. Auditing and Monitoring

6. Principles of documentation
• 1. DATE & TIME
 Document date and time of each recording.
 Record time in conventional manner (E.g. 9am, 6pm etc) or
according to the 24 hour clock (military clock)
 Avoid recording in advance.
• 2. Legibility
 Entries must be legible and easy to read.
 Writing must be clear.
• Very important in recording numbers and medical
terms

7. Principles of documentation
• 3. Correct Spelling
 Correct spelling is essential for accuracy.
• 4. Permanence
 Entries should be done in dark ink.
 It helps to identify changes and allows duplication
• 5.Accepted Terminology
 Use commonly accepted abbreviations, symbols and
terms that are specified by the agency

8. Principles of documentation
• 6. Factual
 Descriptive objective information about what nurse
sees, hears, feels and smells.
 Use of inference without supporting data is not
acceptable.
 Vague terms like appear, seem or apparently is not
accepted.
 Include objective signs of problems.
 Subjective data is documented in client’s exact words
within quotation marks.

9. Principles of documentation
• 7.Accurate
 Use of exact measurement establishes accuracy.eg. Intake
450ml of water than writing adequate amount of water.
 Clients name and identifying information is written on each
page.
 Before making any entry in the chart makes sure that it is
correct.
 Chart only your observations and actions to be accountable.
• If any mistakes occur while recording, draw a line
through it and write above or next to original entry
with your initials or name. Do not erase, blot or use
correction fluids.

10. Principles of documentation
8. Appropriateness
Record information's pertaining to the client
health problems& care only.

11. Principles of documentation
9. Completeness
Document all necessary information's.
It should give a clear picture of what took
place Complete pertinent assessment data such
as vital signs, wound drainage, client
complaints, which was notified and what
interventions are carried out are recorded.

12. Principles of documentation
• 10. Current
 Timely entries are must Keeping record at bed side
may facilitate immediate documentation
• 11. CONCISENESS
 (BRIEVITY)Recording need to be brief as well as
complete to save time in communication
 Client’s name and the word client can be omitted E g.
“perspiring profusely. Respiration shallow. 28/mt ”
Use accepted abbreviations18. 13

13. Principles of documentation
• 12. ORGANIZED
 Information should have logical manner. E g.
description of pain, nurses assessment and
interventions and the client response
 This helps in preventing any omission of information.
Easy to read.
• 13. SIGNATURE
 Each recording is signed by the nurse Signature
includes the name and the title in computerized
charting nurse will have his or her own code.

14. Principles of documentation
• 14. Confidentiality
All the client’s record are confidential files
The information in the chart is personal as well
as legal.
Record shouldn't be copied without the
permission of the client
.Nurse should not allow any outsiders to verify
the client record.

15. Consequences of Inadequate Documentation
• Consequences of Inadequate
Documentation
 Fragmented care
Repetition of tasks
Delayed therapy
Omitted therapy
Delayed recovery

16. Types of documentation:
RECORD
 Record is a permanent written communication
that documents information relevant to a
client’s health care management, e.g. a client
chart is a continuing account of client’s health
care status and need.
Conduct training and research work
Assess health problems.

17. Methods:
1 Source Oriented traditional client record
2 Problem Oriented Medical Record (POMR):
3PIE Charting (Problem, intervention, evaluation):
4- Focus charting:
5- Charting by exception (CBE)

18. Methodof documentation :
1) Source Oriented traditional client record
 It is the client chart, information about a
particular problem is distributed throughout
the record
 e.g. if a patient had left hemi plegia ,data
about this problem must be found in the
physician history sheet, in the nurses notes,
in the physical therapist record and in the
social service record

19. • Components of a source oriented record:
Admission sheet (face) – initial nursing
assessment – graphic record – daily care
record – special flow sheets - medication
record –nurse’s & physical examination
findings – physician order sheet – physician
progress notes – consultations record –
diagnostic reports –– referral summery –
patient consent

20. disadvantage
advantage
is that information about a particular
client problem is scattered throughout
the chart, so it is difficult to find
chronological information on a client
problems and progress
These records are convenient because
care provider from each discipline can
easily locate the forms on which to
record data & it is easy to trace the
information specific to one’s
discipline

21. Methodsof documentation :
2) Problem Oriented Medical Record (POMR):
 In the POMR, established by Lawrence weed in the1960s, data
arranged according to the problems the client has rather than
the source of information.
• Soap Used For Problem-Oriented Charts
• S – Subjective. What Pt Tells Y
ou
• . O– Objective. What You Observe, See
• .A– Assessment. What Y
ou Think Is Going On Based On
Your Data.
• P – Plan. What Y
ouAre Going To Do.

22. • Advantages:
• Encourage collaboration
• The problem list in the front of the chart alerts
caregivers to the client and make it easier to track the
status of each problem
• Disadvantage:
• Caregivers differ in their ability to use the required charting
format
• It takes constant vigilance to maintain up to date problem
• It is inefficient because assessment &interventions repeated to
more than one problem list

23. Basic component of POMR:
Database – problem list – plan of care – progress
notes.
• In addition, flow sheets & discharge notes
added to the record as needed

24. Methodsof documentation
3. PIE Charting (Problem, intervention,
evaluation):
Similar to SOAP charting both are problem-
oriented PIE comes from the Nursing Process;
SOAP comes from a Medical Model.
P Problem
I -Intervention
E –Evaluation

25. Advantages:
The PIE system eliminate the traditional care plan and
incorporate an ongoing care plan into the progress notes
The nurse doesn’t have to create and update and separate
plan
Disadvantages:
Must review all the nursing notes before giving care to
determine which problems are current and which
interventions were effectiv

26. Methodsof documentation :
4. Focus charting:
 A method of identifying and organizing the narrative documentation of all
client concerns.
 Uses a columnar format within the progress notes to distinguish the entry
from other recordings in the narrative notes (Date & time; Focus; Progress
note)
 The progress notes are organized into; Data (D) ,Action (A),
• Response (R)
Example of focus charting
• Date & Time Focus:
• 09./5/.2019 Acute pain related to surgical incision
Progress notes:
D: Patient reports
pain as 7/10 on 0 to 10 scales.
• A: Given morphine 1mg IV at 2335.
• R: Patient reports pain as 1/10 at 2355.

27. • Advantage
Provide a holistic perspective of the client &
the client needs
Provide a nursing process framework for the
progress notes DAR
You doesn’t need to have all three categories or
recorded in ordered

28. Methodsof documentation :
5. Charting by exception
Uses flow sheet emphasis on abnormal
(what is abnormal for this patient.
Although it may be abnormal for the
“normal” person, if it is abnormal for your
patient on a consistent basis, it is no
longer considered an “exception

29. Forms for Recording Data
1- The Carded
• is used as a reference throughout the shift and during change-
of-shift reports.
 Client data (e.g. name, age, admission date, allergy)
 Medical diagnoses and nursing diagnoses
 Medical orders, list of medications
 Activities, diagnostic tests, or specific data on the pt.
 Provides a concise method of organizing and recording data
about a client, making information recording data about a
client, making information readily accessible to all members of
the health team.

30. Forms for Recording Data
2. Flow Sheets
 The information on flow sheets can be formatted to
meet the specific needs of the client.
 (e.g.: graphic sheets for vital signs, intake & output
record, skin assessment record).
3. Nurses’ Progress Notes
 Used to document the client’s condition, problems
and complaints, interventions, responses,
achievement of outcomes.

31. Forms for Recording Data
• 4. Discharge Summary
Client’s status at admission and discharge.
Brief summary of client’s care.
Interventions and education outcomes.
Resolved problems and continuing need.
Referrals
Client instructions.

32. REPORT
• DEFINITION
Reports are oral or written exchanges of
information shared between care givers of
workers in a number of ways.
Areport Summarize the service of the
personnel and of the agency

33. PURPOSES of REPORT
1. Report is an essential tool to communication
2. To show the kind and amount of services rendered
over a specific period.
3. To illustrate progress in teaching goals.
4. As an aid in studying health condition.
5. As an aid in planning.
6. To interpret the services to the public and to the other
interested agencies.

34. Criteria for good Report
1 Made promptly.
2 Clear, concise, and complete.
3 If it is written all pertinent, identifying data are
included-the date and time, the people concerned, the
situation, the signature of the person making the
report.
4It is clearly stated and well organized
5-Important points are emphasized.
6-In case of oral reports they are clearly expressed and
presented in an interesting manner.

35. Types OF REPORT
Types OF REPORT
1) Change-of-shift reports:
2) Transfer and discharge reports:
3) Telephone report:
4) Incident report

36. Types OF REPORT
1) Change-of-shift reports:
 The face-to-face report permits the listener to ask questions during
the report; written and tape-recorded reports are often briefer and
less time consuming.
 Reports are sometimes given at the bedside, and clients as well as
nurses may participate in the exchange of information.
2) Transfer discharge reports and:
 -Nurse report a summary of patient’s condition and care when
transferring patients from one unit or institution or agency to another
(e.g., from the post anesthesia care unit to a surgical floor) and when
discharging patients. The nurse making the report should concisely
summarize all the patient data that care givers nee to provide
immediate care.

37. Types OF REPORT
3) Telephone report:
 Telephones can link health care professionals immediately
and enables nurses to receive and give critical information
about patients in a timely fashion.
 Reporting Telephone Reports and Orders Report transfers,
communicate referrals, obtain client data, solve problems,
and inform a physician and/or client’s family members
regarding a change in the client’s condition.
• Telephone orders are documented in the nurses’
progress notes and the physician order sheet

38. Types OF REPORT
4) Incident report:
 It is also a variance or occurrence report, is a tool used by
health care agencies to document the occurrence of anything
out of the ordinary that results in or has the potential to result
in harm to a patient, employee, or visitor.
 These reports are used for quality improvement and shouldn’t
be used for disciplinary action against staff members.
 They are a means of identifying risks.
 Incident reports improve the management and treatments of
patients by identify high-risk patterns and initiating in-services
programs to prevent future problems.

39. • While incident reporting, the following points are to be kept in
mind:
 The nurse who witnessed the incident or who found the patient at the
time of incident should fill the report.
 The report should be completed as soon as possible.
 The nurse describe in concise what happened specifically objective
terms.
 The nurse doesn’t interpret or attempt to explain the cause of the
incident.
 The nurse objectively the clients, conditions when the incident was
discovered.
 Any measures taken by the nurse, other nurses, or doctors at the time
of the incident are reported.
 No nurse is blamed in an incident report.
 The report is submitted as soon as possible to the appropriate
authority.
• The nurse should never make a photocopy of the incident
report

40. • The nurse includes the following information in an
incident report:
 Identify the client by name, initials, and hospital or
identification number.
 Give the date, and place of the incident.
 Describe the facts of the incident.Avoid any conclusions
or blame. Describe the incident as you saw it even if
your impressions differ from those of others.
 Incorporate the client's account of the incident.
 State the client’s comments by using direct quotes.
 Identify all witnesses to the incident.
• Identify any equipment by number and any
medication by name and dosage

41. Electronic Documentation
Definition of electronic documentation:
It allows nurses to use computers to restore
client data (client assessment, medication
administration, client teaching, progress notes,
care plan updating, and client acuity).

42. Electronic documentation in hospital

43. Guidelines of using of electronic documentation:
1. Must be comprehensive, accurate, timely, and clearly identify
who provided what care.
2. Never reveal or allow anyone else access to your personal
identification number or password as these are, in fact,
electronic signatures.
3. Inform your immediate supervisor if there is suspicion that an
assigned personal identification code is being used by
someone else.
4. Change passwords at frequent and irregular intervals (as per
agency policy).
5. Choose passwords that are not easily deciphered.
6. Log off when not using the system or when leaving the
terminal.
7. Maintain confidentiality of all information.

44. Advantage and Disadvantage of electronic
documentation
Advantage
• 1-different electronic documentation:
• 2-Facilitate quickly
• 3-Providers at different locations.
• 4-Access by different providers at the same time.
• 5-Increases accuracy and legibility
• 6-Reduced error or omission.
• 7-Enhance quality of documentation
• 8-.Improve communication between health care
providers

45. Advantage and Disadvantage of
electronic documentation
Disadvantage
1 Computer downtime: systems can crash or break
down, making information temporarily unavailable.
2 Computerized systems can threaten a patient’s right to
privacy, Confidentiality may be a problem.
3 Cost: includes the cost of software and hardware, cost
of the training, and cost of supervisory involvement
during the transitional period of change.

46. Role of nurse manager in documentation:
1. Anurse manager must assume responsibility for ensuring
complete and accurate documentation.
2. Assist staff in adhering to both clinical and documentation
standards.
3. Provide continuing education, professional feedback, and input
into policy and documentation-system changes whenever
possible
4. Must ensure that nursing staff comply with up-to-date standards,
it is equally important to ensure that they document that
compliance accurately and completely.
5. Ensure that the nursing staff follows the established policies of
the organization.
6. Emphasizing the importance of documentation through written
guidelines, policies, job descriptions, and performance
appraisals.

47. Thank you…