Hernandez, Rocelyn P.

BSN - IV
DOCUMENTATION
EVALUATION
ACTION TREND
Introduction
Documentation within a clients medical record is a
vital aspect of nursing care or practice.
The nursing documentation must be accurate,
comprehensive and flexible.
Information in the client records provides a
detailed account of the level of quality of nursing
care delivered to clients.
Accurate and effective documentation ensures
continuity of care, saves time and prevent
duplication or error in the patient care.
A.DOCUMENTATION
What is documentation?
It is the proper, systematic and
permanent recording of information.

It is an organized way of documenting

data as per time, place, circumstances,
and attribution.
 Nursing documentation serves many
diverse, complex and important
functions from ensuring consistency
of clinical care and good,
communication between
practitioners.
Used as evidence in a court of law.
Basis that every patients have
received an appropriate, high-
quality and evidence-based care.
Purpose and Importance of records
Communication
Legal documentation
Financial Billing
Nursing Research
Prevent errors and duplication
Planning of Care
Characteristics of Documentation
Factual
Accurate
Completeness
Current
Organized
 Factual record contains descriptive, objective
information about what a nurse sees, hears, feels and
smells.
Accurate the use of exact measurements establishes
accuracy and use of an institution accepted
abbreviations, symbols and system of measures.
Completeness information should have a full
information and the record entry needs to be complete
appropriately.
Current timely documentation is a vital principles in
documentation.
Organized as a Nurse you need to communicate
information in a logical order.
Methods of Documentation
1. Narrative Documentation
2. Problem Oriented Medical Record (
POMR)
Data Base
Problem List
Nursing Care Plan
Progress notes
1. Narrative documentation
refers to the most common
traditional method for recording
and documentation of nursing care.
2. Problem Oriented Medical
Record (POMR) is a method
of documentation that emphasize
the clients problems. The data are
organized by problem or diagnosis.
Problem Oriented Medical Record (PORM)
Data Base all available assessment
information pertaining to the client such as
history and physical assessment, nutrition,
nurses admission history and laboratory
reports. The Data Base is the foundation for
identifying client problems and planning of
care.
Problem List- includes the clients both
physiological, psychological, social, cultural,
developmental and environmental needs.
 Nursing Care Plan Nurses develop
a care plan for each problem. These
care of plans include nursing
diagnosis, outcomes and
interventions.
Progress Notes Health care team
members monitor and recorded the
progress of a clients problems.
 Safety
In documentation, safety is to provide
care for the client and to yourself by
means of : recording all the
assessments, planning, actions, and the
interventions youve done with the
client.
Consistency of purpose.
Recording all the assessment,
planning, implementation,
and other procedures done
with the client, from the
diagnosis to prognosis.
 Standardization
Using the standard way of
recording all the data
gathered for the patients
care and all the
procedures done to him/her.
 Improvement.
Assessing whether the
clients condition has
improved with all the
interventions done to
him/her to meet your goal.
B. EVALUATION
The term Evaluation is derived
from the word valoir which means
to be WORTH.
A decision making process that leads
to suggestions for actions to improve
participants; effectiveness and
program efficiency.
Purpose of Evaluation
To encourage health care
provider promote an ongoing
innovative approach.

To encourage individual
professional growth in areas of
interest to the employee.
Patient satisfaction is defined as a
health care recipients reaction to
the context, process, and result of
the health service experience.

Patient satisfaction is defined as the

extent of resemblance between the
expected quality care and the
actual received care.
Evaluating Patient Satisfaction
Data about patient satisfaction equips nurses with
useful information about the structure, process and
outcome of nursing care.

It is a requirement for therapeutic treatment and is

equivalent to self therapy. Satisfied patients help
themselves get healed faster because they are more
willing to comply with the treatment and adhere to
instructions of health care providers.
Components of Evaluation of Patient Satisfaction
Evaluation of the programs and activities of
various departments including outpatient care,
inpatient care, overall health education activities.
Evaluation of the various resources available in
the hospital for effective health care.
Evaluation of effectiveness of hospital personnel
including medical staff.
Services are relevant to the needs of the
population it serves.
Application to Nursing Services
Need for Evaluation
According to WHO, Evaluation of Health
services, is the systematic process of determining
the extent to which an action or sets of actions
were successful in the achievement of
predetermined objectives. It involves measurement
of adequacy, efficacy, effectiveness and efficiency
of the service being evaluated.
It renders possible the reallocation of priorities,
changes in the assessment of needs, the planning
and implementation of care and the management
of resources.
Aspects of Evaluation
Patient Outcomes
Evaluation of the Competence of
the worker
Evaluation of Resources
Recording and Classification System
Types of Evaluation
Summative Evaluation it
evaluates the progress towards an
established outcomes.
Formative evaluation it analyzes
the response to a specific
intervention.
Evaluation as a function of Nursing Management

Fayol defined as verifying whether

everything occurs in conformity with the
plan adopted, the instructions issued and
principles established.
Urwick defines controlling or evaluating
as seeing the everything is being carried
out in accordance with the plan which has
been given and the principles which have
been laid down.
C. Action
Three Levels of Organization:
Organizational Level - strategic,
design/structure, and deployment of
resources

Process Level - process improvement and

reengineering interventions

Job/Performer Level - coaching, performance

management, and training interventions
Short Term Care
To provide medical care for
duration of less than 60 days.
Usually occurs in a hospital
setting.
Resident medical staff available.
Intervention of family not
necessary.
Long Term Care
To provide medical and holistic care
in excess of 60 days.
May occur in a facility or at home.
Professional staff on-call 24 hours.
May also be administered by family.