documentation in nursing

Documentation in NursingDocumentation in Nursing

Mahmood AhmedMahmood Ahmed

(BS Year II Student)(BS Year II Student)

College of Nursing JPMCCollege of Nursing JPMC

KarachiKarachi

Objectives:Objectives:

At the end of this presentation the participants At the end of this presentation the participants will be able to:will be able to:

Define documentationDefine documentation List the purposes of documentationList the purposes of documentation List the principles of documentationList the principles of documentation List the guidelines of documentationList the guidelines of documentation Define the tools of documentationDefine the tools of documentation List the methods of documentationList the methods of documentation Importance of documentationImportance of documentation

Definition of Documentation:Definition of Documentation:

It is any written or electronically It is any written or electronically generated information about a client that generated information about a client that describes the care or service provided to describes the care or service provided to that clientthat client

Documentation is the key - If it is not Documentation is the key - If it is not written it did not happenwritten it did not happen

Purposes of Documentation:Purposes of Documentation:

CommunicatesCommunicates information information accurately accurately Effectively and timelyEffectively and timely Financial billingFinancial billing EducationEducation AssessmentAssessment ResearchResearch AuditingAuditing

Professional accountability Professional accountability and responsibilityand responsibility

Quality assuranceQuality assurance ReimbursementReimbursement Prevention of deficiencies Prevention of deficiencies

and doublingand doubling MonitoringMonitoring Legal and practice standards Legal and practice standards

and protectionand protection Legal recordLegal record

Principles of Documentation:Principles of Documentation:

Medical and Nursing record should be Medical and Nursing record should be complete and legiblecomplete and legible

Frequency of documentation is ultimately a Frequency of documentation is ultimately a professional judgmentprofessional judgment

The documentation records events The documentation records events chronologically and in a timely mannerchronologically and in a timely manner

The documentation is concise, accurate, and The documentation is concise, accurate, and contemporaneouscontemporaneous

The documentation is in an approved formatThe documentation is in an approved format

Principles of Documentation:Principles of Documentation:

The documentation uses approved The documentation uses approved abbreviationsabbreviations

It contains only entries recorded by the It contains only entries recorded by the practitioner who provided the carepractitioner who provided the care

Auditing and monitoringAuditing and monitoring Documentation is a written care planDocumentation is a written care plan Comprehensive flexible and dynamicComprehensive flexible and dynamic Reflect current standardsReflect current standards Documentation should support the intensity of Documentation should support the intensity of

the patient's evaluationthe patient's evaluation

Guidelines for Guidelines for Documentation:Documentation:

FactualFactual AccurateAccurate CompleteComplete CurrentCurrent Organized interventionOrganized intervention

Tools of Documentation:Tools of Documentation:

Data base formsData base forms Plan of care formPlan of care form Progress notes formsProgress notes forms Nursing assessment sheetNursing assessment sheet Worksheets and kardexesWorksheets and kardexes Flow sheets and checklistsFlow sheets and checklists Monitoring stripsMonitoring strips Vital signs chart Vital signs chart Fluid balance chartFluid balance chart Medicine / drug chartMedicine / drug chart

Consent formConsent form IncidentIncident Consultation sheetConsultation sheet Diagnostic resultsDiagnostic results Graphic sheetGraphic sheet Client education recordClient education record Health care team recordHealth care team record Discharge plan and Discharge plan and

summarysummary Advance directiveAdvance directive

Methods of Documentation:Methods of Documentation:

Narrative documentationNarrative documentation Source-oriented chartingSource-oriented charting Problem oriented medical records or SOAP/ SOAPIER Problem oriented medical records or SOAP/ SOAPIER

charting stands forcharting stands for SS Subjective data Subjective data OO Objective data Objective data A A Assessment Assessment PP Plan Plan II Intervention Intervention EE Evaluation Evaluation RR Revision Revision


PIE chartingPIE charting ProblemProblem InterventionIntervention EvaluationEvaluation Focus Charting or DARFocus Charting or DAR DataData ActionAction ResponseResponse

Critical pathway; is a Critical pathway; is a comprehensive , comprehensive , standard plan of care standard plan of care for specific case for specific case situationsituation

Charting by Charting by exception (CBE); exception (CBE); document only document only deviations from pre-deviations from pre-established norms.established norms.


Use of TechnologyUse of Technology Electronic documentationElectronic documentation Fax transmissionFax transmission Telephone ordersTelephone orders Letter writingLetter writing The envelopeThe envelope

Importance of Importance of documentation:documentation:

Enables a multi-professional search for Enables a multi-professional search for information use in decision-makinginformation use in decision-making

Gives information about the nursing processGives information about the nursing process Provides statistics and reports for the planning Provides statistics and reports for the planning

and managing of activitiesand managing of activities Documentation facilitates communicationDocumentation facilitates communication Decreases the potential for miscommunication Decreases the potential for miscommunication

and errors.and errors. Documentation promotes good nursing careDocumentation promotes good nursing care To meet professional and legal standardsTo meet professional and legal standards

Conclusion:Conclusion:

Nursing documentation:Nursing documentation: a nursing process approach a nursing process approach clearly and concisely provides guidelines for clearly and concisely provides guidelines for appropriate and careful documentation of care.appropriate and careful documentation of care.

Accurate documentation shows that patients receive Accurate documentation shows that patients receive care, and care providers are controlling costs and care, and care providers are controlling costs and resources.resources.

Special attention focuses on the latest documentation Special attention focuses on the latest documentation issues specific to specialty settings, such as acute issues specific to specialty settings, such as acute care, home care, and long-term care, and a variety of care, home care, and long-term care, and a variety of clinical specialties, such as psychiatrics, pediatrics, and clinical specialties, such as psychiatrics, pediatrics, and critical care.critical care.

Acknowledgement:Acknowledgement:

Special thanks for support ofSpecial thanks for support of Dr. M. Iqbal Afridi JPMC KarachiDr. M. Iqbal Afridi JPMC Karachi Madam Mehwish Nadir Khan Principal CON Madam Mehwish Nadir Khan Principal CON

JPMC KarachiJPMC Karachi Madam Munira All College of Nursing JPMC Madam Munira All College of Nursing JPMC

KarachiKarachi Dr. Razi Masood LNH KarachiDr. Razi Masood LNH Karachi Sir. S. Bashir Shah Principal CON JPMC Sir. S. Bashir Shah Principal CON JPMC

KarachiKarachi

References:References:

Nursing and Midwifery Council (2002). Guidelines for Nursing and Midwifery Council (2002). Guidelines for records and record keeping. NMC, Londonrecords and record keeping. NMC, London

Ellen Thomas E. (1994). Nursing Documentation USA. Ellen Thomas E. (1994). Nursing Documentation USA. LippincottLippincott

Lois White.(2000). Foundations of Nursing. USA Lois White.(2000). Foundations of Nursing. USA Delmar. Thomson Learning.Delmar. Thomson Learning.

Tong B .C. and Phipps W.J.(1985). Medical Surgical Tong B .C. and Phipps W.J.(1985). Medical Surgical Nursing. (3rd Edition). Mosby Boston.Nursing. (3rd Edition). Mosby Boston.

Carpenito L.JK. (2000) Nursing Diagnosis: Application Carpenito L.JK. (2000) Nursing Diagnosis: Application to Clinical Practice. 7th Edition, J.B. Lippincott to Clinical Practice. 7th Edition, J.B. Lippincott Company New York.Company New York.

documentation in nursing

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