BURAIDAH C ENTRAL H OSPITAL

Department : NURSING SERVICE Policy Index : PP-BCH-NR/GNR-025-DPPE Title : NURSING DOCUMENTATION Applies to : All Nursing Staff Effective Date : 01-01-1432 H New Replace Number :

B. C. H.

DPP

XXXXX

Number of Pages: 3 Review Due : 01-12-1433 H

1. PURPOSE: 1.1 To provide proficient communication among nurses. 1.2 To provide a permanent, legal written document. 1.3 To maintain, accurate timely appropriate informative nursing records. 1.4 To provide a continuity of nursing care. 1.5 To allow for nurses of professional information so that problem areas are identified and
solutions recommended. 1.6 To provide information for research and education towards improvement of health care management.

2. DEFINITIONS : 2.1 Nursing Documentation serves as a permanent record of patient information and care ; is a written record of a patients progress and the provided nursing care utilizing the nursing process : ( Assessment, Nursing Diagnosis, Planning, Implementation, and Evaluation.)

3. POLICY : 3.1 Documentation and reporting of patients condition required adherence to the highest
standards of confidentiality.

3.2 Documentation must be carried out every time a nurse writes her notes in the nurse
progress record and includes the response of the patient to his / her treatment.
Prepared by: Kauthar Fajardo Staff Nurse

3.3

Nursing documentation must reflect consideration for each persons basic dignity. Approval
Approved by: Ahmad Abdulla Al - Omar Hospital Director Page Number: 1/3 Stamp

Form Index: BCH-QM-009-E

4. PROCEDURES : 4.1. Write neatly and legibly.

4.2. Use proper spelling and grammar.: 4.2.1 Write clear and concise sentences. 4.2.2 Avoid useless and unnecessary words. 4.2.3 Clearly identify the subject of the sentence. Consult the dictionary if in doubt. 4.3. Follow when writing notes ( according to Hospital Policy) : 4.3.1 Use black Pen. 4.3.2 Use military time during each entry. 4.4. Use authorized / standard abbreviations only. 4.5. Transcribe orders carefully : 4.5.1 Check each order and write your name, date and time on the right hand side paralell tothe doctors name and signature who wrote the order. 4.5.2. If in doubt, ask the doctor, who wrote the orders for clarification. 4.6. Avoid taking telephone / verbal orders whenever possible. But if you must take one, repeat the order and patient's name. 4.7 Document complete information about medication.: 4.7.1 Write the date, time, and initials. 4.7.2 Write your name and specimen initials at the bottom of the medication sheet. 4.7.3 Document sites of all parenteral injections. 4.7.4 When you omit a medication, document why ? 4.7.5 If the doctor orders a medication / dose, you feel is inappropriate, contact the doctor, clarify and discuss. 4.8. Chart Promptly.: 4.8.1 Chart as soon as an observation, nursing care, treatment or procedure is done. 4.8.2 Chart the response of patient in the treatment given. 4.9. Never chart nursing care or observations ahead of time. 4.10 Clearly identify care given by another member of the health care team. 4.11. Dont leave any blank spaces on chart forms.: 4.11.1 Write entries in the appropriate spaces. 4.11.2 In case a space is left out, draw line across and write the word space, with black pen. 4.12. Correctly identify late entries : 4.12.1 If chart was available when it was needed, when a patient is taken for ultrasound. 4.12.2 If you forgot to add important information after notes have been completed. 4.12.3 If you forgot to write on a particular chart. 4.12.4 Procedures for late entry.: 4.12.4.1 Add the entry to the first available first. 4.12.4.2 Label the entry Late Entry. 4.12.4.3 Record the date and time of entry. 4.12.4.4 Record the date and time it should have been made. 4.12.4.5 If you anticipate having to make late entry, dont ask other nurses to leave some blank for you. 4.13. Correct mistakes entries properly :
Policy Number: PP-BCH-NR/GNR-025-DPP-E Title: NURSING DOCUMENTATION Page Number : 2/3 Approval Stamp

Form Index: BCH-QM-009-E

4.13.1 Never try to cover up an error by using correction fluid or scratching it. 4.13.2 Procedure for correcting an entry : 4.13.2.1 Draw a single line through entry.

4.13.2.2 Write Mistaken Entry or ME, date and your initials above the words. 4.14. Dont sound tentative : 4.14.1 Be exact and specific. Avoid words such as appears, apparent, these words conclude that you are not sure what you are doing or what has been done. 4.15. Write your full name legibly : 4.15.1 When writing your notes on the last line of the page. 4.15.2 When closing your notes at the end of your shift. 4.15.3 When carrying out doctors orders. 4.15.4 Pre - operative checklist sheet.

5. FORMS AND EQUIPMENTS :

Nurses Progress Notes / Nurses Notes. 5.2 Patients Medical Record. 5.3 Pen, Black Ink.

5.1

6. REFERENCES : 6.1 Ministry of Health Policy And Procedures Manual.

7. APPENDIX :
7.1 N/A.

8. APPROVAL :

Name Prepared by: Kauthar Fajardo 1.Abdulla Obeid Al-Harby Reviewed by: 2.Ehab El Husseiny Ibrahim 3.Manae Al-Belaihy Approved by: Ahmad Abdulla Al-Omar

Position Staff Nurse Nursing Director QM Director Medical Director Hospital Director

Signature

Date
22-11-1431 H 24-11-1431 H 29-11-1431 H 29-11-1431 H 01-12-1431 H

Policy Number: PP-BCH-NR/GNR-025-DPP-E

Title: NURSING DOCUMENTATION

Page Number : 3/3

Approval Stamp

Form Index: BCH-QM-009-E

Policy Number: PP-BCH-NR/GNR-025-DPP-E

Title: NURSING DOCUMENTATION

Page Number : 4/3

Approval Stamp

Form Index: BCH-QM-009-E