Foundation of Nursing Documentation in nursing

Principles of documentation

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.

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

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.

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

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

Elements of Effective Documentation Correcting a documentation error

Correcting a documentation error

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.

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

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

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.

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

Problem-Oriented Charting (POMR)

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.

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).

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

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

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

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

Reporting Summary reports Walking rounds Telephone reports and orders Incident reports

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

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.