DOCUMENTATION

DEFINITION
Documentation in Nursing Practice is
anything written or electronically
generated that describes the status
of client on the care or services given
to that client ( Potter and Perry,
2010)

PURPOSES
Communication and Continuity of Care
all health care team members should have
access to information upon which to plan and
evaluate their interventions.
all health care team members require accurate
information about clients to ensure the
development of an organized comprehensive care
plan.
The risk of inaccurate or incomplete
documentation is: care that is fragmented, tasks
that are repeated and therapies which could be
delayed or omitted.

 Quality Improvement/Assurance and Risk

Management
Clear, complete and accurate nursing
documentation facilitates quality
improvement initiatives and risk management
analysis for clients, staff and organizations.
Through chart audits and performance
reviews documentation is used to evaluate
quality of services and appropriateness of
care

 Establishes Professional
Accountability
Documentation is a valuable method of
demonstrating that nursing knowledge,
judgment and skills have been applied
within a nurse-client relationship in
accordance with the code of ethics for
nurses.

 Legal Reasons
The clients record is a legal document and can
be used as evidence in a court of law or in a
professional conduct proceeding.
Documentation should provide a chronological
record of events in client care and delivery of
services.
Courts may use the health record to
reconstruct events, establish time and dates,
refresh ones memory and to substantiate
and/or resolve conflicts in testimony

 Expanding the Science of Nursing

Health records serve as a valuable and major
source of data for nursing and health related
research.
Data obtained from health records is also used in
health research to assess nursing interventions,
evaluate client outcomes, and determine the
efficiency and effectiveness of care. The type of
research made possible through the information
in health records can enable nurses to further
improve nursing practice.

Principles in Documentation

Factual
Accurate
Complete
Timely
Concise
Legible
Confidentiality

FACTUAL
Descriptive objective information
about what the nurse sees, hears,
feels, smells and think
Includes objective signs of problems
Subjective data is documented in
clients exact words within quotation
marks

ACCURATE
Use of exact measurement
establishes accuracy
e.g. Intake of 400ml of water then
writing adequate amount of water

COMPLETE
Condition change
Patients responses especially unusual, undesired or
ineffective response.
Communication with patient family
Entries in all spaces on all relevant assessment form.
Use N/A or other designation per policy for items that
do apply to your patient.
Do not leave blank

TIMELY
Document date & time of each recording
Record time in conventional manner (e.g. 9:00am
to 6:00pm or according to the 24 hours clock)
Avoid recording in advance (this practice is illegal
falsification of the records contributes to errors
and confusion and threatens patient safety.

CONSICE
Recording need to be brief as well as
complete to save time and communication

LEGIBLE
Using black pen, clear enough to be
read, readable particularly handwriting
Any mistakes occur while recording draw
a line through it and write above or next
to original entry with your initial or name.

CONFIDENTIALITY
Technology does not change clients rights
to privacy of health information. Whether
documentation is paper-based, electronic or
in any other format, maintaining
confidentiality of all information in a health
record is essential, and relates to access,
storage, retrieval and transmission of a
clients information.

Role of the nurse in documentation?

Medication Administration
Every hospitals should have specific policies and
procedures related to documentation of medication
administration. The general requirements for this type of
documentation include: ( 10 rights should be followed)
Date
Actual time medications are administrated
Names of medications
Routes of medications
Sites of administration when appropriate
Dosage administered
Nurses signature/designation

Verbal Orders and Telephone Orders

The expectation is that authorized prescribers will write
medication orders whenever possible. However, registered
nurses can accept verbal medication orders from authorized
prescribers (either face-to-face or by telephone) when it is in the
best interest of a client and there are no reasonable alternatives.
Situations in which verbal orders would be considered acceptable
include:
urgent or emergency situations when it is impractical for a
prescriber to interrupt client care and write the medication order
when a prescriber is not present and direction is urgently required
by a registered nurse to provide appropriate client care.

Collaboration with other Health Care Professionals

There is a current trend toward interdisciplinary practice. This
way of documenting is intended to eliminate duplication,
enhance efficient use of time and enrich client outcomes through
team collaboration. Collaborative documentation enables
healthcare professionals of all disciplines to share the same
documentation tools. Examples of such tools are clinical
pathways which reflect interdisciplinary care and integrated,
interdisciplinary patient progress notes

Collaboration with multidisciplinary team

There is a current trend toward
interdisciplinary practice. This way of
documenting is intended to eliminate
duplication, enhance efficient use of
time and enrich client outcomes
through team collaboration.
Collaborative documentation enables
healthcare professionals of all
disciplines to share the same
documentation.

Plan of Care
Effective client-focused documentation should
also include a plan of care.

Admission, Transfer, Transport and Discharge

Information
Accurate and concise documentation on
admission, transfer, transport and discharge
provides baseline data for subsequent care and
follow up. Nursing documentation should reflect
information on the clients status at discharge, any
instructions provided (verbal and written),
arrangements for follow-up care and evidence of the
clients understanding, and family involvement as
appropriate.

Client Education
The following aspects of client education
should be documented in the health record:
both formal (planned) and informal
(unplanned) teaching
materials used to educate
method of teaching (written, visual, verbal,
auditory and instructional aids)
involvement of patient and/or family
evaluation of teaching objectives with
validation of client comprehension and learning
any follow up required.

All Aspects of the Nursing Process

nursing process demonstrates that an RN has fulfilled her/his duty of care.
unique contribution of nursing to the care of clients.
any information that is clinically significant should be documented.

To determine what is essential to document, for each episode of

care or service the health record should contain:
a clear, concise statement of client status (including: physical,
psychological, spiritual)
relevant assessment data (include client/family comments as appropriate)
all on-going monitoring and communications
the care/service provided (all interventions, including advocacy, counseling,
consultation and teaching)
an evaluation of outcomes, including the clients response and plans for
follow up
discharge planning.

Failure to document evaluation is a common deficiency in charting.

 Incident Reports
An incident is an event which is not consistent
with the routine operations of the unit or of
client care (Perry and Potter, 2010). Examples of
incidents include patient falls, medication errors,
needle stick injuries, or any circumstances that
places clients or staff at risk of injury. Incidents
are generally recorded in two places, in the
clients medical record and in an incident report,
which is separate from the chart.

Do's and Don'ts of Nursing Documentation

Do's
Check that you have the correct file before you begin
writing.
Make sure your documentation reflects the nursing
process.
Write legibly.
Chart the time you gave a medication, the
administration route, and the patient's response.
Chart precautions or preventive measures used, such as
bed rails.
Record each phone call to a physician, including the
exact time, message, and response.

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Do's..
Chart patient care at the time you provide it.
If you remember an important point after
you've completed your documentation, chart
the information with a notation that it's a
"late entry." Include the date and time of the
late entry.
Document often enough to tell the whole
story.
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Don'ts
Don't chart a symptom, such as "c/o pain," without also
charting what you did about it.

Don't alter a patient's record - this is a criminal offense.

Don't use shorthand or abbreviations that aren't widely
accepted.

Don't write imprecise descriptions, such as "a large

amount."

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Don't
Don't chart what someone else said, heard, felt,
or smelled unless the information is critical. In
that case, use quotations and attribute the remarks
appropriately.

Don't chart care ahead of time - something may

happen and you may be unable to actually give
the care you've charted. Charting care that you
haven't done is considered fraud.
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