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1. Nursing Documentation
Ahmad Thanin

2. What is Documentation
Effective communication among health professionals and is a vital to
the quality of client care.
Health personal communicate through :
• Discussion
• Is informal oral consideration of a subject by two or more health care personnel to
identify a problem or establish strategies to resolve a problem
• Reports
• is oral , written, or computer-based communication intended to convey information to
others.
• For instance, nurse always report on clients at the end of hospital work shift.
• Records record
• Is written or computer based the process of making an entry on a client medical
record

3. Why Nursing Documentation is important 1
•It Helps Communicate Between Health Care Team And Prevents Fragmentation,
Repetition, And Delays In Client Care.
Communication :
•We Use Data From The Client’s Record To Establish Nursing Care Plan For That Client.
Planning Client Care :
•An Audit Is A Review Of Client Records For Quality Assurance Purposes
Auditing Health Agencies :
•The treatment plans for a number of clients with the same health problem can yield
information helpful in treating another client.
Research:

4. Why Nursing Documentation is important 2
•Students in health disciplines often use client records as educational tools.
•A record can frequently provide a comprehensive view of the client, the illness,
effective treatment strategies, and factors that affect the outcome of the illness.
Education
•Documentation Also Helps A Facility Receive Reimbursement From The Federal
Government And Insurance Companies
Reimbursement :
•The Client Record Is Legal Document And Is Usually Admissible In Court As Evidence.
Legal Documentation :
•Information from records may assist health care planners to identify agency needs,
such as overutilized and underutilized hospital services
Health care analysis:

5. Documentation Guidelines
Correct Patient identification are on every page of the record.
Never record opinions or assumptions
Do not chart for someone else
Chart as close as possible to the time care was performed.
Document if medications not given or treatment not completed) &
reason & action taken above or beside the entry and signed

6. Confidentiality of computer records
Personal
password is
needed to enter
and sign off
computer files
After logging on,
never leave a
computer
terminal
unattended
Do not leave
client information
displayed on the
monitor where
others may see it
Know the facility
policy and
procedure for
correcting an
entry error

7. Assessment
Nursing problem/ Nursing diagnosis
Planning
Implementation
Evaluation

8. Nursing Process
•Is a systematic collection of data to determine the patient’s health status and to identify any
actual or potential health problems.
Assessment
•Organize, analyze, synthesize, and summarize the assessment data to identify patient strengths
and health problems to formulate nursing diagnoses.
Nursing diagnosis
•Development of goals and a care plan designed to assist the patient in resolving the nursing
diagnoses
Planning
•when you put your care plan into action.
•encompasses all nursing interventions directed at solving the patient’s problem and meeting
health care needs.
Implementation
•During the evaluation, you must decide whether the interventions carried out have enabled the
patient to achieve the desired outcomes.
Evaluation

9. Admission Nursing
Assessment
An initial database , nursing
history.
The nurse generally records
ongoing assessments or
reassessments on flow
sheets or nursing progress
notes.

10. Nursing Care plan
The clinical record include evidence of client assessment , nursing diagnoses and/or client
needs , nursing interventions, client outcomes, and evidence of a current nursing care
plan.

11. Types of
nursing
care plans
• is written for each client.
• the form varies from agency to agency
according to the needs of the client and the
department.
• most forms have three columns :
• one for nursing diagnosis,
• second for expected outcomes,
• third for nursing interventions.
Traditional care plan:
• were developed to save documentation time.
• these plans maybe based on an institution's
standards of practice, thereby helping to
provide a high quality of nursing care.
• must be individualized by the nurse in order
to adequately address individual client needs.
.
standardized care plans:

12. Tools of Nursing Documentation
•A typical form used to record the initial database obtained from the nursing history and
physical assessment.
Nursing Assessment
•Are forms that provide a quick overview of basic patient care information, often referred
to during change-of-shift reports and throughout the shift?
Kardex
•The purpose of progress notes is to inform ongoing patient problems and needs, pertinent
nursing observation, and progress toward meeting expected outcomes.
Nursing Progress Notes
•a standardized approach to communication which can be used in any situation. It stands
for Introduction, Situation, Background, Assessment and Recommendation
ISBAR

13. Kardexes
is widely used , concise method of organizing and recording data about a client , making
information quickly accessible to all health professional
it consists of a series of cards kept in a portable index file or on computer-generated
forms and can be quickly accessed to reveal specific data.
it is a temporary worksheet written in pencil for ease in recording frequent changes in
details of a client's care.
The information on kardex may be organized into sections , for example :
• Patient information about the client such as name , room number , age , admission, type of surgery and date.
• Allergies
• list of medication , with the date of order and the times of administration for each.
• list of intravenous fluid , with dates of infusion.
• list of daily treatment and procedure , such as irrigation , dressing change
• list of diagnostic procedures ordered such as x-ray or laboratory test. –
• A problem list , stated goal, and approaches of nursing goal

14. • A flow sheet enable nurses to record nursing data quickly and concisely and provides an easy to read record
of the client's condition over time.
Flow sheets:
• indicate body temperature , pulse , respiratory rate , blood pressure and weight. in some agencies may
include admission or postoperative day, bowel movement and activity.
Graphic record:
• all routes of fluid loss or output are measured and recorded.
Intake and output record:
• include designated areas for date of medication order , the expiration date, the medication name and dose.
medication administration record:
• these record may include categories related to stage of skin injury, drainage, odor, culture information and
treatment.
skin assessment record
• progress note made by the nurse provides information about the progress a client is making toward
achieving desired outcomes.
• in addition to assessment and reassessment data progress notes include information about client problems
and nursing intervention.
progress note :

15. Nursing Discharge / Referral summaries
Discharge note and referral summary are completed when the client is being
discharged and transferred to another institution or to a home setting where a vist
by a community health nurse is required.
If the discharge plan is given directly to the client and family, it is imperative that
instructions be written in terms that can be readily understood.
•( for example : medications , treatments, and activities should be written in layman's terms, and use of
medical abbreviations ( such as ad lib ) should be avoided.
If a client is transferred within the facility or form a long-term facility to a hospital,
a report needs to accompany the client to ensure continuity of care in the new
area.
•it should include all components of the discharge instructions, but also describe the condition of the
client before the transfer.
•any teaching client instruction that has been done should also be described and recorded.

16. Content of Discharge/Referral summaries 1
Description of client's physical, mental, and emotional status at
discharge or transfer.
Resolve health problems.
Unresolved continuing health problems and continuing care needs
may include a review-of systems checklist.
Treatments that are to be continued.
Current medications.

17. Content of Discharge/Referral summaries 2
Restrictions that relate to
•activity.
•diet.
•bathing.
Functional self care abilities in terms of vision, hearing, speech, . . . etc.
Comfort level
Support networks.
Client education provided in relation to disease process, special treatment or care, follow up
appointments.
Discharge destination and mode of discharge.
Referral services.

18. General Guidelines
Write legibly.
•Date and time each entry
•Use correct grammar and spelling
•Chart nursing intervention chronologically.
•Fill each line completely.
Do not leave blank lines between entries. Draw a single line through blank space.
Do not use erasures or correcting fluids.
•A single line should be drawn through and incorrect entry and “error” should be printed
the information contained in their patient health record will be kept confidential.
Make sure your documentation reflects the nursing process and your professional
responsibilities.

19. Date and Time
• document the date and time of each recording. (e. g. ,
6/2/2017 , 9: 00 AM )
Date:
• follow the facility’s policy about the frequency of
documenting and adjust the frequency as client's condition
indicates;
• for example, a client whose blood pressure is changing
requires more frequent documentation than a client whose
blood pressure is constant.
Timing :

20. Signature
Each recording on the nursing notes is
signed by the nurse making it.
• includes the name and title; for example, "susan J.
Green, RN" or "SJ Green, RN. "
• some agencies have a signature sheet and after
signing this sheet, nurses can use their initials.
• with computerized charting, each nurse has his or
her own code, which allows the documentation to
be identified

21. Telephone Reports
Health professionals
frequently report about a
client by the telephone.
The nurse receive a
telephone report should
document
Date
TIME
NAME
SUBJECT
SIGNATURE

22. TELEPHONE ORDER
Physicians Often Order A Therapy (E. G. , A Medication)
For A Client By Telephone.
Many facilities Allow Only Registered Nurses To Take
Telephone Orders.
While Physician Gives The Order,
• Write It Down And
• Repeat It Back To The Physician
• To confirm Accuracy.

23. GUIDELINES FOR TELEPHONE ORDER 1
Know the state nursing board’s position on who
can give and accept verbal and phone order.
Know the facility’s policy regarding phone
orders.
Do not accept an order from a prescriber you
do not know.
Ask the prescriber to speak slowly and clearly.
Ask the prescriber to spell out the medication if
you are not familiar with it.
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24. GUIDELINES FOR TELEPHONE ORDER 2
Question the drug, dosage, or change if they
seem inappropriate for this client.
Read the order back to the prescriber at the
end.
write the order on the physician’s order sheet.
when writing a dosage always put a number
before a decimal.
follow agency protocol about the prescribes
protocol for signing telephone orders.
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25. ISBAR

27. DO AND DON’T OF NURSING
DOCUMENTATION
DO DON’T
• Chart a change in a client’s condition and show
that follow-up.
• Read the nurses’ notes prior to care to determine
if there has been a change in the client’s
condition.
• Be timely: “but a late entry is better than no
entry”.
• Correct charting errors.
• Chart the client’s response to interventions.
• Review your notes.
• Use objective, specific, and factual descriptions.
• Chart all teaching.
• Leave blank space for a colleague to chart later.
• Chart in advance of the event. (e. g, procedure,
medication).
• Use vague terms.
• Chart for someone else.
• Record assumptions or words reflecting bias.
• Alter a record even if requested by a superior or a
physician.
• Use “patient” or “client” as it is their chart.

28. REMEMBER
No recording
should be
done before
providing
nursing care.
Not Written
, Not done