Foundation of Nursing

Documentation in nursing

Principles of documentation

By the end of this lesson the student

participant will be able to:

1) Explain the purposes of documentation

in health care.

2) Discuss the principles of effective

documentation.

Learning outcome

3) Describe various methods of

documentation.

4) Describe various types of documentation

records.

5) Describe the latest advances in

computerized documentation

Learning outcome cont’d

Definitions of documentation

1) Documentation in nursing practice is

any thing written or electronically

generated that describes the status of

client on the care or services given to

that client.

Written evidence of:

2) The interactions between & among health professionals, clients, their families, and health care organizations

3) The administration of tests, procedures, treatments, & client education

4) The results or client’s response to these diagnostic tests & interventions

Definitions of documentation cont’d

purposes

1) Communication.

2) Education.

3) Research

4) Planning client care.

5) legal professional stander

6) Reimbursement.( for a facility to obtain payment)

7) Health care analysis

Elements of Effective Documentation

Correcting a documentation error

Correcting a documentation error

Nursing documentation and progress notes that

are filled with misspelled words & poor grammar

create a negative impression.

(lawyer (may infer that a person with poor

spelling and grammar is uneducated &care less.

The importance of using Proper spelling & grammar of

documentation in nursing practice

Example of common errors on nursing flow

• Fecal heart tone heard.

• Patient observed to be seeping quietly.

• The pelvic exam was done on the floor.

• Vaginal packing out doctor in

Methods of Documentation

1. Problem-Oriented Charting (POMR) Uses a structured, logical format called

S.O.A.P.• S: subjective data•O: objective data•A: assessment• P: plan

2. Uses flow sheets to record routine care.• A discharge summary addresses each

problem.• SOAP entries are usually made at least

every 24 hours on any unresolved problem.

• SOAP was developed on a medical model.

Methods of Documentation cont’d

16-14

• SOAPIE and SOAPIER refer to formats that add: I: Intervention E: Evaluation R: Revision

Methods of Documentation cont’d

Problem-Oriented Charting (POMR)

PIE Charting:

1) PIE charting is a nursing model.–P: Problem–I: Intervention–E: Evaluation

2) Assessment flow sheets

3) Nurses’ progress notes with an integrated plan of care.

Methods of Documentation cont’d

4) Computerized Documentation

a. Increases the quality of documentation and save time.

b. Increases legibility and accuracy.

c. Enhances implementation of the nursing process.

d. Enhances the systematic approach to client care.

e. Provides standardized nursing terminology).

Methods of Documentation cont’d

Forms for Recording Data

1) Kardex

2) Flow Sheets

3) Nurses’ Progress Notes

4) Discharge Summary

Forms for Recording Data cont’d

Discharge Summarya. Client’s status at admission &

discharge

b. Brief summary of client’s care

c. Interventions & education outcomes

d. Resolved problems & continuing need

e. Referrals

f. Client instructions

Reporting• Verbal communication of data regarding

the client’s health status ,needs, treatments

outcomes, and responses

• Summary of current critical information to

facilitate clinical decision making and

continuity of client care

Reporting

• Reporting is based on the nursing process,

standards of care & legal, ethical principles.

• Reports require participation from everyone

present.

Reporting

1. Summary reports

2. Walking rounds

3. Telephone reports and orders

4. Incident reports

Summary Reports Commonly occur at change of shift When client is transferred). Assessment data Primary medical & nursing diagnoses Recent changes in condition, adjustments in

plan of care, & progress toward expected outcomes

Client or family complaints

Incident Reports

• Used to document any unusual occurrence or

accident in the delivery of client care.

• The incident report is not part of the medical

record, but it may be used later in litigation.