Académique Documents
Professionnel Documents
Culture Documents
Faculty of Nursing
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Purpose of Documentation
1. Communication
Documentation is fundamentally communication
that reflects the client’s perspective on his/her health, the
care provided, the effect of care and the continuity of care.
Effective documentation assists clients to make future
care decisions.
Accurate documentation also reflects the effectiveness of
the care provided.
Accurate documentation provides a reliable, permanent
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2. Accountability
The health record demonstrates nurses’
accountability and gives credit to nurses for their
professional practice.
It is used to determine responsibility and may be
used in legal proceedings.
Legislative issues: failing to keep records as
required, falsifying a record, signing or issuing a
false or misleading statement, giving information
about a client without consent and storage and
retrieval of documentation.
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3. Quality improvement
Information from the health record is often used
to evaluate professional practice during quality
improvement processes, such as performance
reviews, accreditation, legislated inspections and
board reviews ()األمناء.
Clear documentation facilitates the evaluation of
the client’s progress toward desired outcomes.
It enables nurses to identify and address areas
that need improvement.
Poor documentation provides incomplete or no
written evidence of the quality of care provided.6
4. Research
Health records can be a valuable source of data
for health research.
Health records can be used to assess nursing
interventions and evaluate client outcomes, as
well as to identify care issues.
Accurately recorded information is essential to
provide accurate research data.
Through research, nurses can improve nursing
practice.
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5. Funding and resource management
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Core Standards for Documentation
or “OK”;
Includes what was observed and avoids
statements such as “appears to” and “seems to”
when describing observations;
Includes signatures or initials;
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Monitoring strips
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Documentation content
Assessment
Documenting the assessment of a client includes
recording the subjective and objective data.
Objective data can be observed (e.g., swelling, bleeding,
crying) or measured (e.g., heart rate, blood pressure,
temperature)
Subjective data such as statements or feedback from the
client
Subjective data are clearly identified as such by using
quotation marks or other marks to distinguish it from
objective data.
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Third–party information
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Documentation methods
Some agencies may combine elements of different
documentation methods and formats to document care
effectively.
Regardless of the method, the health record must present
a clear picture of the nurse’s assessment, actions and
outcomes.
Common methods include charting by exception, focus
charting, SOAP/ SOAPIER and narrative documentation.
May be Paper or Paperless (Electronic health records)
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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 19
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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.