Nurses Notes Writing and Documentation

8/13/2019 Nurses Notes Writing and Documentation

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Dr Nayyar RazaMBBS, DHPM, MPH, M.ScEpidemiologist and Public Health Specialist

Khyber Teaching Hospital, Peshawar







Documentation is the process ofcommunicating in written form aboutessential facts for the maintenance ofcontinous history of events over a period oftime

Record is the permanent written

communication that documents informationrelevent to the patient health caremanagement



Reports are oral or written exchange ofinformation shared between nurses or a

number of persons. Reporting is communication of information

to another individual



“ The Nurse has a duty to maintainconfidenmtiality of all patient information”

(ANA Code of Ethics 2001)

The record are used in client conferences,clinics, rounds, client studies, and writtenpapers. However names or identity of thepatients should not be disclosed



Communication

Record serves as vehicle by which different healthprofessionals who interact with a patient communicate

with each other Planning Patient Care

Each health professional uses data from patient records toplan health care for that patient

Auditing Health Agencies Review for Quality Assurance Process



Research

Information in a record can be valuable source of data forresearch. The treatment plans for a number of patients

with same health problems can yield information helpfulin treating other patients

Education

A record can frequently provide comprehensive view of

patient illness, effective treatment, strategies and factorsthat affect outcome of the illness



Reimbursement

Records are required for reimbursement of money topateint depending on his illness and treatment

Legal Documentation Required in Court of Law or for medicolegal purposes

Health Care Analysis

Assessment of health care needs by health planners



Date and Time Exact Date and Time should be recorded when notes are

being written

Timing No recording should be done before providing nursing

care

Legibility

Must be easily read to prevent errors Permanence

Must be written in permanent ink with no cutting



Correct Spelling

Correct spellings are essential as incorrect

spellings gives a very bad impression anddecreases Nurses credibility

Signature

Each record must be signed by nurse writing it. It

should include Name and title, for example

Noreen RN, Staff Nurse



Accuracy

Patient name and identifying information should

be stamped or written on each page of patientclinical records.

Before making any entry ensure that it is the

correct record. Do not identify be Bed No’s etc

Write factual information eg ‘patient refusedmedication (fact) than to write that patient was

uncooperative



When describing something, avoid general words,such as large, good or normal. For example write “ 3cm bruise noted on right anterolateral thigh rather

than writing a small bruise noted on thigh When recording a mistake, draw a line through it

and write the words mistaken entry above or next tooriginal entry, with your initials or name. Do not

erase or use correction fluid Write on every line but never between the lines



Sequence

Document events in the order in which they occur,

such as record assessments, then nursinginterventions, and then patient responses.

Appropriateness

Record only information that pertains to the client

health problems and care. Don’t record irrelevantinformation.



Completeness

Not all data that a nurse obtains from patient can

be recorded. However information that isrecorded needs to be complete and helpful to

health care professionals



Admission Notes Change of Shift Notes

Assessment Notes Progress Notes Transfer and Discharge Notes Client Teaching Notes Symptoms or Complaints



Focus Charting SOAP

SOAPIER A(D)PIE Narrative Charting



With this method of documentation the nurse identifies a“focus” based on the patient concerns or behaviorsdetermined during the assessment. For example a focuscould reflect Current patient concern or behavior such as decreased urinary output

A significant event in the patient treatment, such as return fromsurgery

InFocus Charting, assessment of client status, interventionscarried out and impact of interventions on patient outcomesare organized under the headings of Data, Action andResponse



Sequencing in DEAR is not important. Any any given time any thing from D, E,A,

R can be entered.



Problem oriented Documentation S= Subjective (What patient described) O= Objective (What nurses find on examination)

A= Assessment P= Plan (How to address the problem in terms of

management)

I= Intervention (What the Nurses actually do to addressthe problem)

E= Evaluation (What was the outcome following theintervention) R= Revision (What changes are needed to the health care

plan)



Nursing Diagnosis

and Supporting

Data

Assessment and

Diagnosis

Expected Patient

Outcomes

Planning

Nursing

Interventions

Interventions

Evaluation

Subjective

Objective

Nursing Diagnosis



Narrative Charting is a method in which Nursing

interventions and the impact of these interventions

on client outcomes are recorded in chronological

order covering a specific time frame. Data is recorded in the progress notes, often

without an organizing framework. Narrative

charting may stand alone or it may be

complemented by other tools, such as flow sheets

and checklists



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The process of selecting one actionfrom alternatives

Decision making is the learned &

scientific problem solving process. Managers spend much time making

decisions and solving problems,

especially non routine situations



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1) Identify the problem:- defining the problem. What is wrong? Where is

improvement needed? - begins when the nurse manager perceives a

gap between what is actually happening andwhat should be happening.

- The nurse manager can identify the problem byanalyzing situation.



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- What is the desirable situation?- What are the presenting symptoms?

- What are the discrepancies?

- Who is involved?

- When? Where ? How?

* Develop Feasible hypotheses, and elimination ofhypotheses that fail to conform to the facts.

- Feasible hypotheses should be further tested forcausal validity.

- By analyzing available information, manager shouldbegin exploring possible solutions



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2) Explore alternatives: - If situation is not covered by policy, manager must draw

on his education and experience, but it may beinadequate.

- more experienced manager had more alternatives to be

suggested for solving a variety of problems.

- Health care is changing rapidly manager should learnhow others are solving similar problems.

- This can be done through continuing education,

professional meetings, review of the literature, and

brainstorming with staff.



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3) Choose most desirable alternative: - One alternative is not always clearly superior

to all others.

- Manager must try to balance multiple factorssuch as pt safety, staff acceptance, morale,public acceptance, cost, and risk of failure.

* The following questions may be asked:- Will this decision accomplish the stated

objectives? (yes or no)- Dose it maximize effectiveness and efficiency?

use available resources before seeking outsideassistance.

- Can the decision be implemented?If not, it will not solve the problem



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4) Implement decision:- The manager will need to communicate

the decision to appropriate staffsmoothly to win the cooperation

5) Evaluate results: - Evaluate the results of the chosen

alternative.- Be alert: solutions to old problems

sometimes create new problems, so youneed additional decisions.

Documents

Nurses Notes Writing and Documentation