NURSING

DOCUMENTATION

NLK Sulisnadewi, MKep.,Ns.Sp.Kep.An

Why Document?
Accreditation
Reimbursement
Communication (Continuity,
education)
Legal (Not documented, not done)
 Documentation is any written or
electronically generated
information about a client that
describes the care or service
provided to that client.
 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 clients response to,
diagnostic tests and interventions.
 PURPOSE OF
DOCUMENTATION
 TO FACILITATE
COMUNICATION
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.
TO PROMOTE GOOD
NURSING CARE
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
TO MEET PROFESIONAL AND
LEGAL STANDAR
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 nurses documentation may be
used as evidence in legal proceedings
such as lawsuits, coroners inquests,
and disciplinary hearings through
professional regulatory bodies
ELEMENTS OF EFECTIVE
DOCUMENTATION
USE A COMMON VOCABULARY.
WRITE LEGIBLY & NEATLYC. USE
ONLY AUTHORIZED ABBREVIATIONS
& SYMBOLS. ( t.i.d, b.i.d, q.i.d, p.r.n,
p.o, p.c, a.c, h.s.)
EMPLOY FACTUAL & TIME
SEQUENCE ORGANIZATIONE.
DOCUMENT ACCURATELY &
COMPLETELY, INCLUDING ANY
ERRORS.
PRINCIPLES OF EFECTIVE
DOCUMENTATION
ASSESSMENT
NURSING DIAGNOSIS
PLANNING (S.M.A.R.T.)
IMPLEMENTATIONE.
EVALUATION
 METHOD OF
DOCUMENTATION
SOAP/SOAPIE(R) CHARTING
NARRATIVE CHARTING
FOCUS CHARTING
 SOAP/SOAPIE(R)
CHARTING
SOAP/SOAPIE(R) charting is a
problem- oriented approach to
documentation where by the nurse
identifies and lists client problems;
documentation then follows
according to the identified
problems.
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 clients
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?)
 S: I feel weak & tired as verbalized by the patient
O: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,
(-)Homanssign, 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) counts
P: 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 circulation
Narrative 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.
 0730H 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 noted With evidence of
Slurred speech, Leg edematous. Left side of the body is
unresponsive to pain stimuli Initial vital signs taken as follows: SPO2
75%; BP 200/110mmHg; 90bpm; RR 24cpm; Temp 38.5C; Weight
150Kg.
0735H Oxygen inhalation started @ 4LPM via nasal cannula.
Seen and examined by Attending Physician-Dr. Salazar with orders
made and 0740H carried out. For MRI, Chest X-Ray (AP) & Lab
Investigation- requested.0745H 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.0746H Venoclysis Started with IVF of Plain NSS 1 Liter
and regulated at KVO rate .
0747H 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.0800H
Endorsed.-------------------------------------NESTOR A. SALAZAR JR., RN.
FOCUS CHARTING
method of documentation, in
which the nurse identifies a
focus based on client concerns
or behaviors determined during
the assessment.
FOCUS (FDAR) CHARTING
F FOCUS
D - DATA (subjective/objective)
A ACTION
R - RESPONSE
NURSING PROCESS
Nursing Process
Specific to the nursing profession
A framework for critical thinking
Its purpose is to:

Diagnose and treat human

responses to actual or potential
health problems
Nursing Process
Organized framework to guide
practice
Problem solving method - client
focused
Systematic- sequential steps
Goal oriented- outcome criteria
Dynamic-always changing, flexible
Utilizes critical thinking processes
5 Steps in the Nursing
Process
Assessment
Nursing
Diagnosis
Planning
Implementing
Evaluating
 Assessment
First step of the Nursing Process
Gather Information/Collect Data
Primary Source - Client / Family
Secondary Source - physical exam,
nursing history, team members, lab reports,
diagnostic tests..
Subjective -from the client (symptom)
I have a headache
Objective - observable data (sign)
Blood Pressure 130/80
Assessment-collecting data
Nursing Interview (history)
Health Assessment -Review of
Systems
Physical Exam
Inspection
Palpation
Percussion
Auscultation
Assessment-collecting data
Make sure information is
complete & accurate
Validate
Interpret and analyze data
Compare to standard norms
Organize and cluster data
Example of Assessment
Obtain info from nursing assessment,
history and physical (H&P) etc...
Client diagnosed with hypertension
B/P 160/90
2 Gm Na diet and antihypertensive
medications were prescribed
Client statement I really dont watch my
salt Its hard to do and I just dont get
it
Nursing Diagnosis
Second step of the Nursing Process
Interpret & analyze clustered data
Identify clients problems and strengths
Formulate Nursing Diagnosis (NANDA :
North American Nursing Diagnosis
Association)-Statement of how the client
is RESPONDING to an actual or
potential problem that requires nursing
intervention
 Nsg Dx vs MD Dx
Within the scope of Within the scope of
nursing practice medical practice
Identify responses Focuses on curing
to health and pathology
illness Stays the same as
Can change from long as the
day to day disease is present
Formulating a Nursing
Diagnosis
Composed of 3 parts:
Problem statement- the clients
response to a problem
Etiology- whats
causing/contributing to the clients
problem
Defining Characteristics- whats
the evidence of the problem
Nursing Diagnosis
Problem( Diagnostic Label)-based on
your assessment of client(gathered
information), pick a problem from the
NANDA list...
Etiology- determine what the problem
is caused by or related to (R/T)...
Defining characteristics- then state as
evidenced by (AEB) the specific facts
the problem is based on...
Example of Nursing Dx
Ineffective therapeutic regimen
management
R/T difficulty maintaining lifestyle
changes and lack of knowledge
AEB B/P= 160/90, dietary sodium
restrictions not being observed,
and client statements of I dont
watch my salt Its hard to do and I
just dont get it.
Types of Nursing Diagnoses
Actual
Imbalanced nutrition; less than body
requirements RT chronic diarrhea, nausea,
and pain AEB height 55 weight 105 lbs.
Risk
Risk for falls RT altered gait and generalized
weakness
Wellness
Family coping: potential for growth RT
unexpected birth of twins.
 Planning
Third step of the Nursing Process
This is when the nurse organizes a
nursing care plan based on the nursing
diagnoses.
Nurse and client formulate goals to help
the client with their problems
Expected outcomes are identified
Interventions (nursing orders) are
selected to aid the client reach these
goals.
Planning Begin by prioritizing client
problems

Prioritize list of
clients nursing
diagnoses using
Maslow
Rank as high,
intermediate or
low
Client specific
Priorities can
change
 Planning
Developing a goal and outcome
statement
EXAMPLE
Goal:
Goal and outcome Client will achieve
statements are client therapeutic
focused. management of
Worded positively disease process.
Measurable, specific Outcome
observable, time- Statement:
limited, and realistic AEB B/P readings of
Goal = broad 110-120 / 70-80 and
statement client statement of
Expected outcome = understanding
objective criterion for importance of
measurement of goal dietary sodium
Utilize NOC as restrictions by day of
standard discharge.
Planning- Types of goals
Short term goals
Long term goals
Cognitive goals
Psychomotor goals
Affective goals
Goals are patient-centered and
SMART
Specific
Measurable
Attainable
Relevant
Time Bound
Pt will walk 50 ft.
Pt will eat 75% of meal
Pt will maintain HR<100
Pt will state pain level is acceptable 6 (0-10)
Planning-select interventions
Interventions are selected and written.
The nurse uses clinical judgment and
professional knowledge to select
appropriate interventions that will aid the
client in reaching their goal.
Interventions should be examined for
feasibility and acceptability to the client
Interventions should be written clearly
and specifically.
Interventions 3 types
Independent ( Nurse initiated )- any
action the nurse can initiate without
direct supervision
Dependent ( Physician initiated )-
nursing actions requiring MD orders
Collaborative- nursing actions
performed jointly with other health care
team members
 Implemention
The fourth step in the Nursing Process
This is the Doing step
Carrying out nursing interventions (orders)
selected during the planning step
This includes monitoring, teaching, further
assessing, reviewing NCP, incorporating
physicians orders and monitoring cost
effectiveness of interventions
 Implementing- Doing
Teach potential
Monitor VS q4h
complications of
Teach client amount of hypertension to instill
sodium restriction, importance of
foods high in sodium, maintaining Na
use of nutrition labels, restrictions
food preparation and Assess for cultural
sodium substitutes
factors affecting
dietary regime
 Implementing Doing
Teach the client- Teach client
hypertension cant be importance of life style
cured but it can be changes: (weight
controlled. reduction, smoking
Remind the client to cessation, increasing
continue medication activity)
even though no S/S Stress the importance
are present. of ongoing follow-up
care even though the
patient feels well.
Evaluation- To determine
effectiveness of NCP
Final step of the Nursing Process but
also done concurrently throughout client care
A comparison of client behavior and/or
response to the established outcome criteria
Continuous review of the nursing care plan
Examines if nursing interventions are working
Determines changes needed to help client
reach stated goals.
 Evaluation
Outcome criteria met? Problem
resolved!
Outcome criteria not fully met?
Continue plan of care- ongoing.
Outcome criteria unobtainable- review
each previous step of NCP and
determine if modification of the NCP is
needed.
Were the nsg interventions
appropriate/effective?