NURSING DOCUMENTATION, RECORD

KEEPINGS AND WRITTEN

COMMUNICATION

Medical History of Patient

M. Deri Ramadhan, S.Kep., Ners, M.Kep

Basic Nursing Care Manual_NED Institute

 The Importance of writting

• Accurate keeping record and careful documentation is

an essential part of Nursing practice.
• High quality record keeping will help you give skilled
and safe care wherever you are working.
• Registered Nurses have a legal and professional duty of
care, and this one includes also the record of our
actions and cares carried out, as also all the
information of the patient.
• Professionals must recognize the importance and
relevance, as well as we must know how to fill registers
correctly and the consequences both in the
professional area and patient´s health
 The Importance of writting

• Records are witness documentary on acts and

professional behaviors where it is collected all the
information about the activity concerning the patient
nurse, his treatment and his evolution.
• Dispose of their corresponding registry Nursing
constituting thus:
v A System of communication betweem the
professionals of the healthcare team.
v Quality of care, to be compared to certain quality
standards.
v A system of evaluation for the management services of
nurses and the cares of patients.
 Clinical History

It Is the set of documents that contains the data,

assessments and information of any kind of
situation and the clinical evolution of a patient in
the course of healthcare process.
Record and documentation should demonstrate:
• Relevant information about your patient.
• What you did in response to their needs.
• A full description of your assessment and the care
planned and given.
 Why we have to record...?

• It´s one more of our functions

• It´s our responsibility
• It´s our duty
• It´s also take care of patients:
To know
it helps us To prevent, to anticipate
To care, to treat
 Who...

• Every nurse
• With every patient that she carries on
• Every time... And at least once for shift
 And ... How?

• Rules and recommendations:

v ObjectivityàMust be written in an objective
manner, without prejudice, value judgments or
opinions personal
v Precision and accuracy àMust be accurate,
complete and trustworthy. The facts should be
recorded in a clear and concise manner. Express
their observations in quantifiable terms.
v Readability and clarity
v Date, shift, signature and professional category
 Documentation

• You will see lots of different charts, forms and documentation. All of
them complete the Medical Patient History
• Nursing Assessment Sheet: contains
• − identification of patient: Patients biographical details (name, age,
sex), weight and height, number of clinical history, medical history
(precedents, diseases, treatments, possibility of pregnancy...),
allergies, diagnosis (reason for admission), surgery procedure, ward
and bed’s number, nurse and doctor responsible, date
 Nursing Assessment Sheet

• − Vital signs: hemodynamic situation (pulse, blood pressure,

temperature, capillary, blood glucose. Display numerically in at least
once for shift and everytime that we observe some important
change in the patient.
• − Treatment and applied messures: oxygen therapy (device, flow,
FiO2), fluid therapy (saline, ringer lactate, glucose/rytme and
quantity), Drugs, antibiotics, analgesics and other medication
 Nursing Assessment Sheet

− Diet: absolute, fasting, clear liquid, basal

− Drainages: type (bladder catheter, nasogastric,
redon, ventricular...), productive or non
(amount and colour)
− Wounds: location, appearance, cares
− Outputs: diuresis, stools, vomiting
− Balance: shift total (intakes-outputs)
 Nursing Assessment Sheet

− Nursing order report:

Before the shift change, the nurse assigned to the patient
must will record assessments charted in the eight hour
period covered:
v The evolution of the patient, how he has spent the
shift, incidents, and changes that have happened,
taken care applied and if it remains slightly hanging
v The nursing needs and problems identified for the care
plan
Nurse responsible sign this record and at the end of shift
report’s will be placed in the patient’s chart
 Preoperatory Report

Objectives:
‒ To identify factors of risk and possible complications.
‒ To maintain the safety of the patient along all its surgical
process.
‒ Preparing the patient for surgery.
Contents:
– Identification of patient
– Surgical Check list
– Personal precedents
– Premedication
– Preparation of the surgical field
 Preoperative Nurse Functions

1. Preserve the privacy of the patient.

2. Inform the patient and family about the date, time
and place scheduled the surgery.
3. Determine the level of knowledge and anxiety
before the surgery. Confirm the explanation
received.
4. Make sure that the patient is in fasting, if needed.
5. Check has been signed informed consent.
 Preoperative Nurse Functions

6. Verify that the necessary laboratory tests has been

made
7. Communicate to the operating room staff special
care needs-
8. Check that the patient carries identification, and
allergy bracelet if necessary.
9. Verify the need of shaved for surgery.
10. Remove rings, bracelets, and remove dentures,
glasses, contact lenses or other prosthesis.
 Preoperative Nurse Functions

11. Remove the nail polish and makeup, if you need

12. Administer enemas, if needed.
13. Administer medication before surgery if necessary.
14. Check that the patient has carried out hygiene prior
to surgery or help in it if it is not self-employed.
15. Check that the patient has placed the garments
according to Protocol.
 Preoperative Nurse Functions

16. Provide information to the family about zones

waiting.
17. The presence of animals is strictly forbidden
18. Prepare the room for the return of the patient
19. Record in the nursing documentation: procedures,
dates and time of surgery, incidents and response of
the patient.
 Nursing Records in ICU
The Critical Care Flow Sheet is a – Fluid Balance.
document that includes specific patient – Neurochecks.
information charted within an 24 hours – Others:
(or less) time frame. The report provides • Patient´s positions.
details of the patient’s condition and
plan of care and can also be used to • Invasive lines control.
track trends in the patient’s progress. It • Test (blood, glucose, urine…)
is primarily used in the ICU. – Nursing Assessment.
–Patient´s identification and relative
information.
– Vital and hemodynamic signs.
– Ventilation and oxygen parameters.
– Medication, drugs and infusions.
 Vital and hemodynamic signs:
The basic chart is used to record pulse, blood
pressure, respiration, temperature, StO2.
Display graphically in 60 minute intervals
minimum, and often as necessary depending on
the patient's condition
• following a colors code:
– HR: blue, represented by a point.
– BP: green, represented by arrows.
– RR: black, represented by a cross.
– Temperature: red, represented by a point.
 Nursing Records in ICU

Medication, drugs and infusions: sail(cross) on having administered the

• Medications administered during the medication.
selected time frame. •It is vital to record all of these, when
• It is transcribed of the sheet of you give a drug and if you cannot give a
treatment of the doctor. drug for one reason (e.g. Physical
condition, contraindication…). Make
– Type medication with its:
sure that this fact is recorded to not
Ø Dose repeat or skip any doses.
Ø Route of administration
Ø Rule hourly
– Marking with a diagonal bar an hour
that it corresponds according to the
established hourly rule, completing the
 Nursing Records in ICU

Fluid therapy Fluid Balance Chart

• Type of serum •It is used to record all fluid intake and
• Quantity fluid output over 24-hour period. The
amounts may be totalled and balance
•The medication that adds "if
calculated at
applicable" and the rhythm of infusion.
•It will be marked with a vector , on 08.00 hours.
line we will register the total volume •Fluid intake incluides oral, nasogastric
that gives under the line and the drops feeding tube and infusions given
per minute corresponding. intravenously.
•Fluid output includes urine, vomit,
aspirate from nasogastric tube,
diarrhoea, drainages…
 Nursing Records in ICU

Neurocheck:
• Neurological observations charts, are using for
recording other specific observations such the:
–Glasgow Coma Scale score for level of
consciousness,
– pupil size and reaction to ligth
– Limb movement
 Nursing Records in ICU

Control of Invasive Lines and Wounds:

• The patient admitted to the ICU is at risk of numerous
complications and special problems.
• Use of multiple and invasive devices predisposes a patient to
infections iatrogenic, that can follow from sepsis.
• The infection is the most common and serious complication
after a surgical intervention. We can and should be avoided.
• Hence, the importance of taking a record and control and
daily monitoring of all these invasive systems and the wounds.
• WE WILL HAVE TO CHECK EVERY SURGICAL WOUND EVERY
DAY AND TREAT IT WHENEVER IT IS NECESSARY.
 Nursing assessment

• Is the sheet where are ü Provenance.

recorded incidents that have ü Motive of admission.
occurred, the description of ü Allergies.
the patient's response to care
ü Personal history.
made also new situations that
arise when patient. ü Initial state of patient to the
income.
• Registers with date, shift, and
legible signature of the nurse ü When they started the current
in each turn. symptoms (if applicable).
• In the assessment of the ü Assessment and identification
critical patient at admission of needs and degree of
must be recorded: autonomy.
 Nursing assessment

• An important function of critical care nurses is to provide

continuous observation of critically ill patients.
• Observation will reduce a patient’s risk of precipitous
deterioration and warns of possible complications that
might arise.
• Observation involves assimilation, interpretation and
evaluation of information, including the patient’s physical
and psychological response to interventions, changes in
condition, the significance of monitored physiological
parameters and the safe functioning of equipment.
• Do a thorough top to toe assessment.
 Nursing assessment

Do a thorough top to toe assessment:

• General appearance (calm, aggitated, distressed, sleepy, lethargic..).
• Brief neuro exam, pupils reactivity, extremity strength.
• Vital signs monitoring.
• Then the chest: heart tones, lung sounds, work of breathing, position and
size of ETT (if applicable).
• Then abdomen: listen, palpate, check placement of NGT/OGT.
• Then foley and color/quality of urine.
• Then to the limbs: movement, pulses, cap refill, temperature…
• IV locations and its condition and operation.
• Then lastly a skin assessment for ulcers, wounds, surgical drainages…
• Also writes all the evidence and proceedings that are pending or planned
for other shifts (for example analytical, TAC, fasting)
Thank You
&
Good Luck...