Principles of Documentation

PRINCIPLES OF PRINCIPLES OF DOCUMENTATIONDOCUMENTATION

Ms. JEENA AEJY Ms. JEENA AEJY

DOCUMENTATION MUST BE DOCUMENTATION MUST BE CONSISTENT WITH CONSISTENT WITH PROFESSIONAL AND AGENCY PROFESSIONAL AND AGENCY STANDERDS, COMPLETE, STANDERDS, COMPLETE, ACCURATE , CONCISE, ACCURATE , CONCISE, FACUAL, ORGANIZED AND FACUAL, ORGANIZED AND TIMELY, LENGTHY, PRUDENT TIMELY, LENGTHY, PRUDENT AND CONFIDENTIAL.AND CONFIDENTIAL.

1. DATE & TIME1. DATE & TIME

Document date and time of Document date and time of eacheach recording. recording. Record time in conventional manner(Eg. Record time in conventional manner(Eg.

9am, 6pm etc)9am, 6pm etc) or according to the 24 hour or according to the 24 hour clock(military clock)clock(military clock)

Avoid recording in advance.Avoid recording in advance.

2.LEGIBILITY2.LEGIBILITY

Entries must be legible Entries must be legible and easy to read.and easy to read.

Writing must be clear.Writing must be clear. Very important in Very important in

recording numbers and recording numbers and medical terms.medical terms.

3.CORRECT SPELLING3.CORRECT SPELLING

Correct spelling is essential for accuracy.Correct spelling is essential for accuracy. If unsure about the spelling use a dictionary If unsure about the spelling use a dictionary

or other resource book.or other resource book.

4.PERMANANCE4.PERMANANCE

Entries should be Entries should be done in dark ink. done in dark ink.

It helps to identify It helps to identify changes and changes and allows allows duplication duplication (Xerox).(Xerox).

5.ACCEPTED TERMINOLOGY5.ACCEPTED TERMINOLOGY

Use commonly accepted abbreviations, Use commonly accepted abbreviations, symbols and terms that are specified by the symbols and terms that are specified by the agencyagency

Use universally accepted abbreviations.Use universally accepted abbreviations.

6.FACTUAL6.FACTUAL Descriptive objective information about Descriptive objective information about

what nurse sees, hears, feels and smells.what nurse sees, hears, feels and smells. Use of inference without supporting data is Use of inference without supporting data is

not acceptable.not acceptable. Vague terms like appears, seems or Vague terms like appears, seems or

apparently is not accepted. apparently is not accepted. Include objective signs of problems.Include objective signs of problems. Subjective data is documented in client’s Subjective data is documented in client’s

exact words within quotation marks.exact words within quotation marks.

7. ACCURATE7. ACCURATE Use of exact measurement establishes accuracy.Use of exact measurement establishes accuracy.

Eg. Intake 450ml of water than writing Eg. Intake 450ml of water than writing adequate amount of water.adequate amount of water.

Clients name and identifying information is Clients name and identifying information is written on each page.written on each page.

Before making any entry in the chart make sure Before making any entry in the chart make sure that it is correct.that it is correct.

Chart only your observations and actions to be Chart only your observations and actions to be accountable.accountable.

If any mistakes occur while recording, If any mistakes occur while recording, draw a line through it and write above or draw a line through it and write above or next to original entry with your initials or next to original entry with your initials or name.name.

Do not erase, blot or use correction fluids.Do not erase, blot or use correction fluids. Follow agencies policy while making Follow agencies policy while making

computerized charting.computerized charting. Write on every line but not in between the Write on every line but not in between the

lines.lines. Draw a line through the blank spaces so that Draw a line through the blank spaces so that

no additional information can be added.no additional information can be added.

8.SEQUENCE8.SEQUENCE Document events in order of occurrence.Document events in order of occurrence.

Eg. Record assessments, then nsg Eg. Record assessments, then nsg interventions and then the client responses.interventions and then the client responses.

Update or delete problems as needed.Update or delete problems as needed.

9. APPROPRIATENESS9. APPROPRIATENESS Record informations pertaining to the Record informations pertaining to the

client health problems& care only.client health problems& care only. Avoid personal informations that are in Avoid personal informations that are in

appropriate.appropriate.

10. COMPLETENESS10. COMPLETENESS Document all necessary informationsDocument all necessary informations It should give a clear picture of what took place.It should give a clear picture of what took place. Complete pertinent assessment data such as Complete pertinent assessment data such as

vital signs, wound drainage, client complaints, vital signs, wound drainage, client complaints, who was notified and what interventions are who was notified and what interventions are carrid out etc are recorded.carrid out etc are recorded.

The following informations should be included The following informations should be included in the chart:in the chart:

A new or changed informationA new or changed information Signs and symptomsSigns and symptoms Client behaviorClient behavior Nursing interventionsNursing interventions MedicationsMedications Physician’s orders carried outPhysician’s orders carried out Client teachingClient teaching Client responseClient response

11.CURRENT11.CURRENT

Timely entries are mustTimely entries are must Keeping record at bed side may Keeping record at bed side may

facilitate immediate facilitate immediate documentationdocumentation

Activities/findings recorded at the time of Activities/findings recorded at the time of occurrence include the followingoccurrence include the following

Vital signsVital signs Administration of drugs or RxAdministration of drugs or Rx Preparations for diagnostic tests or surgeryPreparations for diagnostic tests or surgery Change in the clients health status & who Change in the clients health status & who

was notified.was notified. Admission, transfer, discharge or death of a Admission, transfer, discharge or death of a

client.client. Treatement for a sudden change in client’s Treatement for a sudden change in client’s

status.status.

12. CONCISENESS (BRIEVITY)12. CONCISENESS (BRIEVITY) Recording need to be brief as well as complete Recording need to be brief as well as complete

to save time in communication.to save time in communication. Client’s name and the word client can be Client’s name and the word client can be

omittedomitted

Eg. “perspiring profusely. Respiration shallow. Eg. “perspiring profusely. Respiration shallow. 28/mt”28/mt”

Use accepte abbreviationsUse accepte abbreviations

13. ORGANIZED13. ORGANIZED Information should have logical mannerInformation should have logical manner

Eg. description of pain, nurses assessment and Eg. description of pain, nurses assessment and interventions and the client response.interventions and the client response.

This helps in preventing any omission of This helps in preventing any omission of informations.informations.

Easy to read.Easy to read.

14. SIGNATURE14. SIGNATURE Each recording is signed by the nurse.Each recording is signed by the nurse. Signature includes the name and the title Signature includes the name and the title

In computerized charting nurse will have his or In computerized charting nurse will have his or her own code.her own code.

15.CONFIDENTIALITY15.CONFIDENTIALITY

All the client’s record are confidential filesAll the client’s record are confidential files The information in the chart is personal as The information in the chart is personal as

well as legal.well as legal. Record shouldn't be copied without the Record shouldn't be copied without the

permission of the client.permission of the client. Nurse should not allow any outsiders to Nurse should not allow any outsiders to

verify the client record.verify the client record.

Thank youThank you