DOCUMENTATION

WRITE IT RIGHT!
PRESENTED BY
FIONA AMSTERDAM
EVA AUGUSTE
DAVIA MOFFAT
OBJECTIVES
Documentation
Effective Documenting
Documentation Guidelines
Purpose of Documentation
Methods of Documentation




INTRODUCTION
NURSES IN HOSPITALS ACROSS THE WORLD FEEL BURDENED WITH THE ODIOUS TASK OF
DOCUMENTATION. MANY NURSES THINK DOCUMENTATION TAKES TOO MUCH TIMETIME THEY
WOULD RATHER BE SPENDING WITH PATIENTS AND FAMILIES. EVERY NURSING SCHOOL TEACHES
THE IMPORTANCE OF DOCUMENTATION AND THIS IS REINFORCED IN ALL ACUTE CARE SETTINGS.
YET THE DISCONNECTION BETWEEN DOCUMENTATION AND ESSENTIAL NURSING PRACTICES IS
DISTURBING, WHICH LEADS ME TO ASK, WHAT IS DOCUMENTATION FOR?

AS REQUIRED DOCUMENTATION BECOMES INCREASINGLY STANDARDIZED AND FOCUSED ON
AUDITABLE PERFORMANCE MEASURES, IT MOVES FURTHER AWAY FROM ARTICULATING THOSE
ASPECTS OF NURSING THAT CANNOT BE MADE AUDITABLE. NURSES FIND DOCUMENTATION TO BE
AN ODIOUS TASK BECAUSE THE DOCUMENTATION PROCESS DOES NOT ASK THEM TO
ARTICULATEAND SO ROUTINELY FAILS TO CAPTURENURSES CONCERNS FOR THE PARTICULAR
PATIENT.
WHAT IS DOCUMENTATION?
The process of making an entry on a cliets record is recording, charting or documenting. A clinical
record also called a chart or client record is a legal document that provides evidence of patient care.
Although health are organisations use different systems and forms for documentation, all client records
have the similar information.
Clients documentation should include:
1. Changes in the client's condition
2. The administration of tests, treatments, procedures, and client education, with the
results of or client's response to them
3. The client's response to an intervention
4. The evaluation of expected outcomes
5. Complaints from client or family

GUIDELINES FOR EFFECTIVE
DOCUMENTATION
The clients note is the only permanent legal document that details the nurses interaction with the
patient and is the nurse best defence if a patient or patients surrogate alleges nurses negligence .
Unfortunately there are crucial omissions and in nursing documentation. In addition to meaningless
repetitious entries. And inaccurate entries.
Although these errors might go undetected and have no effect on the patient , they may seriously affect
the care the patient receives, undermining nursing creditability as a professional disciple and cause legal
problems for the nurse responsible action
Nurses and other professional caregivers learn and communicate private information about patients
and their families everyday.
Whiles most nurses staunch advocates of patients rights to privacy and confidentiality. Many nurses
thoughtlessly violate these very rights daily.
DOCUMENTATION GUIDELINES
In order for documentation to serve as a legal document it must be:
Complete
Accurate
Concise
Current
Factual
Organized data communicated in a timely and confidential manner to facilitate care coordination.
CONTENT
Enter information in a complete, accurate, concise ,current and factual manner
Ensure that the documentation reflects the nursing process and professionalism
Record patient findings rather than your interpretation of the patients findings
Avoid words like good, fair , average they may be interpreted differently by other readers.
Avoid generalizations like seem comfortable instead use on a scale of 1 to 10 patient rates 3
for back pain compared to 7 for yesterdays pain.
Document all medical visits and consultants that other nurses should be aware of
Document in a legal prudent manner. Adhere to professional standards
Document nurses response to questionable orders or failure to read. Document in the
patients chart any treatment plans or interventions that you objected to and how the
situation was handled.
Avoid use of stereotype or derogatory terms when charting

TIMING
Chart in a timely manner following agency policy regarding frequency of documentation
Indicate in each entry the time of documenting and the time of pertinent observation and
intervention.
Document intervention to as close a time as possible of their execution.
Never document interventions before carrying it out.
Document what you delegated to other staff members and when that care was provided. This
demonstrates that you made sure the duties you delegated to the staff were provided to the
patient in a timely manner.


FORMAT
Check to make sure that you have the correct chart before writing
Write legibly in dark ink to ensure permanence. Use correct spelling and grammar. Use
standard terminology. Avoid abbreviations that are non-medical and never add texting
language in patient records.
Date and time each entry
Chart nursing interventions chronologically on consecutive lines. Never skip lines, draw a line
between blank spaces.
AACCOUNTABILITY
Sign first initial and last name and title to each entry and do not sign notes describing
interventions not performed by you that you have no way of verifying.
Do not use correction fluid erasers or dittos. Draw one single line through the incorrect entry
and words mistaken entry or error in charting should be printed at the top or beside the
entry and signed.
Identify each page of record with patients name and hospital number.
Ensure patient record is complete before sending it to medical records


CONFIDENTIALITY
Patients have a moral and legal right to expect that the information kept in
their health records will be kept private
Most agencies allow students access to patients record for educational
purposes. Students using patient records are bound professionally and
ethically to keep in strict confidence all the information they learn by reading
patients charts. Actual names of patients should not be used in orall and
written reports.
PURPOSE OF DOCUMENTATION
The two primary purposes for documentation are professional responsibility and
accountability.
It is the professional responsibility of all health care practitioners
Documentation provides evidence of the practitioner's accountability to the
client, the institution, the profession, and society.
Other purposes are communication, legal and practice standards, education,
reimbursement, research, and auditing.

PURPOSE OF DOCUMENTATION CONTD
Communication - a means of communicating and sharing information on the patient's status
throughout the hospitalization with health care team members
Patient care planning - each professional working with the patient has access to the patient's
baseline and ongoing data. Patient responds to the treatment plan from day-to-day is
documented. Modifications of the plan of care are then based on this data.
Audit - patient records may be reviewed to evaluate the quality of care received and to improve
the quality of care as indicated
Research - patient records may be studied by researchers to learn how best to recognize or
treat health problems
Education - clinical manifestations of particular health problems, effective treatment methods,
and factors affecting client goal achievement are documented
PURPOSE OF DOCUMENTATION CONTD
Reimbursement record - insurance companies, Medicare, and Medicaid require written
record of treatments, equipment, and diagnostic procedures before they pay the agency
Legal documentation - a legal document and admissible in court as evidence
Historic document - past information may be pertinent concerning a patient's healthcare
Health care analysis- information from records may assist health care planners to identify
hospital needs such as usage of supplies and services. It could also be used to identify
services that cost the hospital money and those that generate revenue.
METHODS OF DOCUMENTING
Systems of recording and reporting data pertinent to client care have evolved primarily in response to
demands that health care practitioners be held to societal norms, professional standards of practice,
legal and regulatory standards, and institutional policies and standards. The documentation systems
used
today reflect specific needs and preferences of the many health care agencies.

Among the many systems used for documentation are
the following:
1. Narrative charting
2. Source-oriented charting
3. Problem- oriented charting
4. PIE charting
5. Focus charting
6. Charting by exception
7. Computerized documentation
8. Critical pathways
SOURCE-ORIENTED CHARTING:

Narrative recording by each member (source) of the health care team on separate documents.
Features:
a. Each discipline uses a separate record.
Defects:
a. Often resulting in fragmented care.
b. Time-consuming communication between disciplines.
ANY QUESTIONS ?

BIBLIOGRAPHY
Fundamental's of nursing the art and science of nursing care by C. Taylor
Fundamental's of nursing concepts process and practice by B. Kozier & G. Erb
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THANK YOU! GRACIAS!

MERCI!