1. Documentation

2. Prepared by Professor Lubna Abushaikha School of Nursing The University of Jordan

3. Documentation is written evidence of:
The interactions between and among health care professionals, clients, their families, and health care organizations.
The administration of tests, procedures, treatments, and client education.
The results of, or client’s response to, diagnostic tests and interventions

4. Purposes of Documentation
Professional responsibility
Accountability
Communication
Education
Research
Satisfaction of Legal and Practice standards
Reimbursement

5. Documentation as Communication
Documentation is a communication method that confirms the care provided to the client.
It clearly outlines all important information regarding the client.

6. Documentation as Education
The medical record can be used by health care students as a teaching tool.
It is a main source of data for clinical research.

7. Documentation & Research
The medical record is a main source of data for clinical research.

8. Elements of Effective Documentation
Use a common vocabulary.
Write legibly and neatly.
Use only authorized abbreviations and symbols.
Employ factual and time-sequenced organization.
Document accurately and completely, including any errors.

9. Methods of Documentation
Narrative Charting
Source-oriented charting
Problem-oriented charting
PIE charting
DAR/focus charting
Charting by exception
Computerized documentation
Critical pathways

10. Narrative Charting
This traditional method of nursing documentation takes the form of a story written in paragraphs.
Before the advent of flow sheets, this was the only method for documenting care.

11. Source-Oriented Charting
A narrative recording by each member (source) of the health care team on separate records.

12. Problem-Oriented Charting
Focuses on the client’s problem and employs a structured, logical format called SOAP charting:
S: Subjective data (what the client states)
O: Objective data (what is observed/inspected)
A: Assessment
P: Plan

13. PIE Charting
Problem
Intervention
Evaluation

14. Focus/DAR Charting D (data): collect subjective and objective data.
DAR Charting is consisted of three components:
D (data): collect subjective and objective data.
A nursing action: document all nursing actions.
R patient’s response: record the patient’s response to therapy.
The reason for using this type of charting is due to its international use and simplicity.

15. Charting by Exception
A documentation method that requires the nurse to document only deviations from pre-established norms.

16. Computerized documentation
Decreased documentation time.
Increased legibility and accuracy.
Clear, decisive, and concise words.
Statistical analysis of data.
Enhanced implementation of the nursing process.
Enhanced decision making.
Multidisciplinary networking.

17. Critical Pathways
A comprehensive, standard plan of care for specific case situations.
The pathway is monitored to ensure that interventions are performed on time and client outcomes are achieved on time.

18. Examples of nursing documentation
Date/Time Focus Notes 27/4/2015 8:00 a.m. Admission Received awake on bed with intravenous fluid at 500 cc level regulated at 15 gtts/min General appearance Affect and facial expression appropriate to situation. Speech clear. Respiration Rate 20, even, unlabored respirations. No accessory muscles used. Breath sounds clear in all areas. Pain Pain noted at 6 on the number scale. Pain medication administered and pain noted at 3 on same scale 30 minutes later. Rest and sleep Pt reported no sleep problems other than hospital required interruptions. Health education Health education given to pt on compliance with diet regimen. ___________________________________________________________ Signature of RN

19. The patient is 70 years old admitted as a case of chronic obstructive pulmonary disease, complaining of vomiting and dyspnea for 2 days, she is diabetic on insulin therapy for 17 years and hypertensive for 10 years. The patient was doing well till 2 days ago when he started to complain of dyspnea with minimal activity, associated with effort