Foundation of Nursing Documentation in nursing. Principles of documentation.
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Transcript of Foundation of Nursing Documentation in nursing. Principles of documentation.
Foundation of Nursing
Documentation in nursing
Principles of documentation
By the end of this lesson the student
participant will be able to:
1) Explain the purposes of documentation
in health care.
2) Discuss the principles of effective
documentation.
Learning outcome
3) Describe various methods of
documentation.
4) Describe various types of documentation
records.
5) Describe the latest advances in
computerized documentation
Learning outcome cont’d
Definitions of documentation
1) 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.
Written evidence of:
2) The interactions between & among health professionals, clients, their families, and health care organizations
3) The administration of tests, procedures, treatments, & client education
4) The results or client’s response to these diagnostic tests & interventions
Definitions of documentation cont’d
purposes
1) Communication.
2) Education.
3) Research
4) Planning client care.
5) legal professional stander
6) Reimbursement.( for a facility to obtain payment)
7) Health care analysis
Elements of Effective Documentation
Correcting a documentation error
Correcting a documentation error
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.
The importance of using Proper spelling & grammar of
documentation in nursing practice
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
1. Problem-Oriented Charting (POMR) Uses a structured, logical format called
S.O.A.P.• S: subjective data•O: objective data•A: assessment• P: plan
2. 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
16-14
• SOAPIE and SOAPIER refer to formats that add: I: Intervention E: Evaluation R: Revision
Methods of Documentation cont’d
Problem-Oriented Charting (POMR)
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
a. Increases the quality of documentation and save time.
b. Increases legibility and accuracy.
c. Enhances implementation of the nursing process.
d. Enhances the systematic approach to client care.
e. Provides standardized nursing terminology).
Methods of Documentation cont’d
Forms for Recording Data
1) Kardex
2) Flow Sheets
3) Nurses’ Progress Notes
4) Discharge Summary
Forms for Recording Data cont’d
Discharge Summarya. Client’s status at admission &
discharge
b. Brief summary of client’s care
c. Interventions & education outcomes
d. Resolved problems & continuing need
e. Referrals
f. 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
1. Summary reports
2. Walking rounds
3. Telephone reports and orders
4. 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.