1. Foundation of Nursing Documentation in nursing

2. Principles of documentation

3. Learning outcome
By the end of this lesson the student participant will be able to:
Explain the purposes of documentation in health care.
Discuss the principles of effective documentation.

4. Learning outcome cont’d
Describe various methods of documentation.
Describe various types of documentation records.
Describe the latest advances in computerized documentation

5. Definitions of documentation
Documentation in nursing practice is any thing written or electronically generated that describes the status of client on the care or services given to that client.

6. Definitions of documentation cont’d
Written evidence of:
The interactions between & among health professionals, clients, their families, and health care organizations
The administration of tests, procedures, treatments, & client education
The results or client’s response to these diagnostic tests & interventions

7. purposes Communication. Education. Research Planning client care.
legal professional stander
Reimbursement.( for a facility to obtain payment)
Health care analysis

8. Elements of Effective Documentation
Correcting a documentation error

9. Correcting a documentation error

10. The importance of using
Proper spelling & grammar of documentation in nursing practice
Nursing documentation and progress notes that are filled with misspelled words & poor grammar create a negative impression.
(lawyer (may infer that a person with poor spelling and grammar is uneducated &care less.

11. Example of common errors on nursing flow
Fecal heart tone heard.
Patient observed to be seeping quietly.
The pelvic exam was done on the floor.
Vaginal packing out doctor in

12. Methods of Documentation
Problem-Oriented Charting (POMR)
Uses a structured, logical format called S.O.A.P.
S: subjective data
O: objective data
A: assessment
P: plan

13. Methods of Documentation cont’d
Uses flow sheets to record routine care.
A discharge summary addresses each problem.
SOAP entries are usually made at least every 24 hours on any unresolved problem.
SOAP was developed on a medical model.

14. Methods of Documentation cont’d
SOAPIE and SOAPIER refer to formats that add:
I: Intervention
E: Evaluation
R: Revision

15. Problem-Oriented Charting (POMR)

16. Methods of Documentation cont’d
PIE Charting:
1) PIE charting is a nursing model.
P: Problem
I: Intervention
E: Evaluation
2) Assessment flow sheets
3) Nurses’ progress notes with an integrated plan of care.

17. Methods of Documentation cont’d
4) Computerized Documentation
Increases the quality of documentation and save time.
Increases legibility and accuracy.
Enhances implementation of the nursing process.
Enhances the systematic approach to client care.
Provides standardized nursing terminology).

18. Forms for Recording Data
Kardex
Flow Sheets
Nurses’ Progress Notes
Discharge Summary

19. Forms for Recording Data cont’d
Discharge Summary
Client’s status at admission & discharge
Brief summary of client’s care
Interventions & education outcomes
Resolved problems & continuing need
Referrals
Client instructions

20. Reporting
Verbal communication of data regarding the client’s health status ,needs, treatments
outcomes, and responses
Summary of current critical information to facilitate clinical decision making and continuity of client care

21. Reporting
Reporting is based on the nursing process, standards of care & legal, ethical principles.
Reports require participation from everyone present.

22. Reporting Summary reports Walking rounds Telephone reports and orders
Incident reports

23. Summary Reports Commonly occur at change of shift
When client is transferred).
Assessment data
Primary medical & nursing diagnoses
Recent changes in condition, adjustments in plan of care, & progress toward expected outcomes
Client or family complaints

24. Incident Reports
Used to document any unusual occurrence or accident in the delivery of client care.
The incident report is not part of the medical record, but it may be used later in litigation.