Prepared by: Hayden S.

Ganta, RN Nursing Educator

Learning Objectives: At the end of 45 minutes, the participants will be able to: Identify the principles and purposes of nursing documentation. 2. Recognize the importance of proper documentation. 3. Familiarize the hospital policy in regards to nursing documentation.
1.

Nursing Documentation
It refers to written or electronically generated information about a client, describing the care or services provided to that client (e.g., charting, recording, nurses notes, or progress notes).

Nursing Documentation should clearly describe:

an assessment of the clients health status, nursing interventions carried out and the impact of these interventions on client outcomes a care plan or health plan reflecting the needs and goals of the client any proposed or needed changes to the care plan information reported to a physician or other healthcare provider and, when applicable, that providers response advocacy undertaken by the nurse on behalf of the client

Purposes of Documentation
Communication and Continuity of Care Quality Improvement/ Assurance and Risk Management Legal Records Professional Accountability Research and Education

Principles of Documentation
Factual Accurate Complete Current Organized

Tools for Documentation

1.Worksheets and Kardexes 2.Client Care Plans 3.Flow Sheets and Checklists 4.Monitoring Strips

Medication Administration
Date Actual time the medication was given Name of medication Route of Administration

Methods of Documentation
 Focus Charting Patient assessment, interventions and outcomes are organized under the headings of Data, Actions and Response.

 SOAPIE Chart It is a problem-oriented approach of documentation.

S - Subjective O - Objective A - Analysis/Assessment P - Plan I - Intervention E - Evaluation

Narrative Charting It 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.

Guidelines in taking/recording Telephone Orders

Write down the time and date on the physicians order sheet. Write down the order exactly as given by the physician. Read the order back to the physician to ensure it is accurately recorded. Record the physicians name on the order sheet; state telephone order; print your name and sign the entry, along with your designation (e.g., RN). On-site verbal orders also have the potential for error and should be avoided except in urgent or emergency situations (e.g., cardiac arrest).

GENERAL GUIDELINES FOR DOCUMENTATION

Date and Time Timing Legibility Permanence Accepted Terminology Correct Spelling Signature Accuracy Mistaken Entry Blank Spaces Sequence/ Organization Appropriateness Completeness Conciseness

What does it mean???

TID RBS OS NSVD LMP OU Thrice a day Random Blood Sugar Left Eye Normal Spontaneous Vaginal Delivery Last Menstrual Period Both Eyes

SQ KUB FBS OD IVP Tx PRN

Subcutaneous Kidney, Ureter and Bladder Fasting Blood Sugar Right Eye; Once Daily Intravenous Pyelogram Treatment When Necessary/ Pro Re Nata

BID IM ANST CXR BT CPM

Twice a day Intramuscular After Negative Skin Test Chest X-Ray Blood Transfusion Cycles per minute