Documentation
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
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.
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.
Documentation &
Research
The medical record is a main
source of data for clinical
research.
Legal & Practice
Standards
Nurses are responsible for
assessing and documenting
that the client has an
understanding of treatment
prior to intervention.
Two indicators of the above are
Informed Consent and Advance
Informed Consent
A competent client’s ability to make health
care decisions based on full disclosure of
the benefits, risks, and potential
consequences of a recommended
treatment plan.
The client’s agreement to the treatment as
indicated by the client’s signing a consent
form.
Advanced Directives
Written instructions about a client’s health
care preferences regarding life-sustaining
measures. (e.g. living will and durable
power of attorney for health care).
Allows clients, while competent, to
participate in end-of-life decisions.
Documentation &
Reimbursement
Accreditation and
reimbursement agencies
require accurate and thorough
documentation of the nursing
care rendered and the client’s
response to interventions.
Elements of Effective
Documentation
To ensure effective documentation,
nurses should:
Use a common Employ factual and
vocabulary.
time-sequenced
Write legibly and organization.
neatly.
Document
Use only authorized
abbreviations and accurately and
symbols. completely,
including any errors.
Methods of
Documentation
Narrative Focus charting
Charting Charting by
Source- exception
oriented Computerized
charting documentation
Problem- Critical
oriented pathways
charting
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.
Source-Oriented Charting
A narrative recording by each
member (source) of the health
care team on separate records.
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
PIE Charting
PROBLEM
INTERVENTION
EVALUATION
Focus Charting
A documentation method that
uses a column format to chart
data, action, and response
(DAR).
Charting by Exception
A documentation method that
requires the nurse to document
only deviations from pre-
established norms.
Charting by Exception
A documentation method that
requires the nurse to document
only deviations from pre-
established norms.
Computerized
Documentation:
Advantages
Decreased Statistical analysis
documentation time. of data.
Increased legibility Enhanced
and accuracy. implementation of
the nursing process.
Clear, decisive, and
concise words.
Enhanced decision
making.
Multidisciplinary
networking.
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.
Forms for Recording Data
Kardex
Flow Sheets
Nurse’s Progress Notes
Discharge Summary
Kardex
A summary worksheet
reference of basic information
that traditionally is not part of
the record. Usually contains:
Client data (name, age, marital status,
religious preference, physician, family
contact).
Medical diagnoses: listed by priority.
Allergies.
Medical orders (diet, IV therapy, etc.).
Flow Sheets
Vertical or horizontal columns
for recording dates and times
and related assessment and
intervention information. Also
included are notes on:
Client teaching.
Use of special equipment.
IV Therapy.
Nurse’s Progress Notes
Used to document:
Client’s condition, problems, and
complaints.
Interventions.
Client’s response to interventions.
Discharge Summary
Highlights client’s illness and
course of care. Includes:
Client’s status at admission and
discharge.
Brief summary of client’s care.
Intervention and education outcomes.
Resolved problems and continuing care
needs.
Client instructions regarding
medications, diet, food-drug
interactions, activity, treatments,
Trends in Documentation
Nursing Minimum Data Set.
Nursing Diagnoses.
Nursing Intervention
Classification.
Nursing Outcomes Classification.
Nursing Minimum Data
Set
The elements that should be
contained in clinical records and
abstracted for studies on the
effectiveness and costs of
nursing care. Focuses on:
Demographics.
Service.
Nursing care.
Nursing Diagnoses
A clinical judgment about
individual, family, or community
responses to actual or potential
health problems or life processes.
Nursing Intervention
Classification
A comprehensive standardized
language for nursing
interventions organized in a
three-level taxonomy.
Nursing Outcomes
Classification
A classification system that
comprises 190 outcome labels
and corresponding definitions,
measures, indicators, and
references.
Summary Reports
The outlining of information
pertinent to the client’s needs as
identified by the nursing process.
Commonly given at end-of-shift.
