NURSING DOCUMENTATION

Nestor A. Salazar Jr., BSN., R.N.

Speaker

To be able to understand the differences in Methods of Documentation.

Objective:

Documentation is any written or electronically generated information about a client that describes the care or service provided to that client.

NURSING 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.

NURSING DOCUMENTATION

nurses communicate to other nurses and care providers their assessments about the status of clients, nursing interventions that are carried out and the results of these interventions.

Thorough, accurate documentation decreases the potential for miscommunication and errors.

I. PURPOSE OF DOCUMENTATION

A. TO FACILITATE COMMUNICATION

Encourages nurses to assess client progress and determine which interventions are effective and which are ineffective, and identify and document changes to the plan of care as needed.

facilitating nursing research, all of which have the potential to improve the quality of nursing practice and client care.

B. TO PROMOTE GOOD NURSING CARE

Documentation is a valuable method for demonstrating that, within the nurse-client relationship, the nurse has applied nursing knowledge, skills and judgment according to professional standards.

The nurse’s documentation may be used as evidence in legal proceedings such as lawsuits, coroners’ inquests, and disciplinary hearings through professional regulatory bodies.

C. TO MEET PROFESSIONAL & LEGAL STANDARDS

A. USE A COMMON VOCABULARY.B. WRITE LEGIBLY & NEATLYC. USE ONLY AUTHORIZED ABBREVIATIONS &

SYMBOLS. (e.g.; t.i.d, b.i.d, q.i.d, p.r.n, p.o, p.c, a.c, h.s.)

D. EMPLOY FACTUAL & TIME SEQUENCE ORGANIZATION

E. DOCUMENT ACCURATELY & COMPLETELY, INCLUDING ANY ERRORS.

II. ELEMENTS OF EFFECTIVE dOcUmentaTION

A. ASSESSMENTB. NURSING DIAGNOSISC. PLANNING (S.M.A.R.T.)D. IMPLEMENTATIONE. EVALUATION

III. PRINCIPLES OF EFFECTIVE DOCUMENTATION

Kardexes are used to communicate current orders, upcoming tests or surgeries, special diets or the use of aids for independent living specific to an individual client; 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.).◦Activities permitted.

IV. FORMS OF RECORDING DATA

A. KARDEX

KARDEX FORM

Flow sheets and checklists are used to document routine care and observations that are recorded on a regular basis

(e.g., activities of daily living, vital signs, intake and output).

B. FLOW SHEETS & CHECKLIST

Vital Signs Form

ADL Form

Used to document:

◦ Client’s condition, problems, and complaints.

◦ Interventions.

◦ Client’s response to interventions.

◦ Achievement of outcomes.

C. NURSES PROGRESS NOTES

DATE TIME NURSES NOTES SIGNATURE

NURSES PROGRESS NOTES

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, follow-up and other special needs.

D. DISCHARGE SUMMARY

A. SOAP/SOAPIE(R) CHARTING

B. NARRATIVE CHARTING

C. FOCUS CHARTING

V. METHODS OF DOCUMENTATION

SOAP/SOAPIE(R) charting is a problem-oriented approach to documentation whereby the nurse identifies and lists client problems; documentation then follows according to the identified problems.

A. SOAP/SOAPIE(R) CHARTING

S = Subjective data (e.g., how does the client feel?) O =Objective data (e.g., results of the physical exam, relevant

vital signs) A = Assessment (e.g., what is the client’s status?) P =Plan (e.g., does the plan stay the same? is a change

needed?) I =Intervention (e.g., what occurred? what did the nurse do?) E=Evaluation (e.g., what is the client outcome following the

intervention?) R =Revision (e.g., what changes are needed to the care plan?)

A. SOAP/SOAPIE(R) CHARTING

S: “I feel weak & tired” as verbalized by the patientO:Received on bed on supine position conscious and coherent, with intact and

unsoaked incision dressing, (-) breast engorgement, urine (1), (-)BM, unsoaked vaginal/perineal pads with moderate amount of lochia serosa, (-)Homan’ssign, ambulatory, pale buccal mucosa and conjunctiva, hgb count (77), hct (0.33),with initial vital signs taken as follows:BP- 120/80 mmHg, PR-83 bpm, RR-26bpm, Temp.-36.4oC.

A:Altered Tissue Perfusion r/t decrease hgb(77), hct(0.33) countsP:After 2o of nursing intervention, the patient will verbalize understanding of the

condition, treatment/therapy regimen, and will demonstrate behavioral changes to improve circulation.

I: Assessed for physical manifestations of anemia. Assessed for factors that could precipitate to anemia such as bleeding on incision site, excessive lochia and diet. Assessed diet/food preference. Encouraged to increase intake of food rich in iron such as animal liver & green & leafy vegetables when in DAT status. Instructed to watch for sign of bleeding on incision site (soaked dressing) and increase in lochia. Instructed compliance to oral iron supplement intake. Administered due medication

E:Patient verbalized understanding of condition and therapeutic regimen and demonstrated behavioral changes to improve circulationCASE: POSTPARTUM

SOAPIE CHARTING

Narrative charting is a method in which nursing interventions and the impact of these interventions on client outcomes are recorded in chronological order covering a specific time frame.

Data is recorded in the progress notes, often without an organizing framework.

Narrative charting may stand alone or it may be complemented by other tools, such as flow sheets and checklists.

B. NARRATIVE CHARTING

Case: CEREBROVASCULAR ACCIDENT (stroke)

0730H

0735H

0740H

0745H

0746H0747H

0800H

Admitted patient to Emergency Room male 50 years old, conscious, immobile with chief complaints of numbness in Left side of the body.Difficulty of breathing slightly notedWith evidence of Slurred speech, Leg edematous.Left side of the body is unresponsive to pain stimuliInitial vital signs taken as follows: SPO2 75%; BP 200/110mmHg; 90bpm; RR 24cpm; Temp 38.5C; Weight 150Kg. Oxygen inhalation started @ 4LPM via nasal cannula.Seen and examined by Attending Physician-Dr. Salazar with orders made and carried out.For MRI, Chest X-Ray (AP) & Lab Investigation- requested.Foley Catheter F#16 inserted aseptically and attached to Urobag- draining well with yellow colored urine..Vital Sign monitored every 15 minutes & I & O measured every hour.Venoclysis Started with IVF of Plain NSS 1 Liter and regulated at KVO rate .Furosemide 40mg given via slow IV push.Citicoline 100mg loading dose started via IV then every 6 hours after.Fixed and wheeled to ward per stretcher with same IVF on.Endorsed.-------------------------------------NESTOR A. SALAZAR JR., RN.

NARRATIVE CHARTING

method of documentation, in which the nurse identifies a “focus” based on client concerns or behaviors determined during the assessment.

C. FOCUS (FDAR) CHARTING

F - FOCUS D - DATA (subjective/objective)

A - ACTION R - RESPONSE

C. FOCUS (FDAR) CHARTING

• Flexible enough to adapt to any clinical practice setting and promotes interdisciplinary documentation

• Centers on the nursing process, including assessment, planning, implementation and evaluation

• Information is easy to find because data is organized by the focus.

• It promotes communication between all care team members • Encourages regular documentation of patient responses to care • Helps organize documentation so that it is concise and precise • Can be easily adapted to computer based documentation

systems

ADVANTAGES OF FOCUS CHARTING

HOW TO DEVELOP THE FOCUSREFERS TO EXAMPLE

A sign or Symptom Hypotention, or Chest Pain

A patient behavior Inability to ambulate

An acute change in the patient condition LOC, or ICP

A significant event in the patient’s therapy Surgery(e.g “E” Appendectomy)

A special patient need Discharge planning need

DATE TIME

4/10/11 1200H F- Wound dressing

D- Moderate amount, foul smelling drainage from abdominal incision noted. Suture line red swollen and warm to touch; T-39.5C, complaining of pain at the site.-------------------------NESTOR A. SALAZAR JR., RN

A- Dr. N. Salazar notified and informed of patient’s incisional status, orders received. Ketorolac 30mg given via IV as ordered, C&S of wound taken and sent to Lab. Wound cleansed with antibacterial solution and dry dressing applied.------NESTOR A. SALAZAR JR., RN

R- Temp. rechecked- 38C. Patients states incisional pain improving. Dressing remains dry & intact, no discharge noted. Antibiotic initiated as ordered.--------------------------------------NESTOR A. SALAZAR JR., RN

FOCUS CHARTING

In which of the 3 Methods of Documentation you

are going to use in making Nurses Notes for

the Patient? Why?

QUESTION:

THANK YOU!!!!!!!!!