Documentation in

Nursing
By – Mr. Ashish Kamal Reed (RN) (NE)
OUT LINE
1. Introduction
2. Definition of documentation
3. Purpose of documentation
4. Principles of documentation
5. Types of documentation
6. Methods of documentation
7. Forms of recording data
8. Consequences of inadequate documentation
9. Definition of reporting
10. Purpose of reporting
11. Criteria of good report
12. Types of report
13. Importance of record and report
14. Definition of Electronic documentation
15. Guide lines of electronic documentation
16. Advantage and disadvantage of electronic documentation
17. Role of nurse manager during documentation
Introduction
Documentation as Communication Reporting and
recording are the major communication
techniques used by health care providers.

Nursing documentation is a vital component of

safe, ethical and effective nursing practice,
regardless of the context of practice or whether
the documentation is paper-based or electronic.
 Definition of Documentation

Any written or electronically generated information

about a client that describes the care or service
provided to that client. The administration of tests,
procedures, treatments, and client education.
 Purpose of health care
documentation

1. Professional Responsibility and Accountability

2. To facilitate communication
3. To promote good nursing care
4. To meet professional and legal standards
5. Education
6. Research
7. Auditing and Monitoring
Principles of documentation
1.DATE & TIME

 Document date and time of each recording.

 Record time in conventional manner (E.g. 9am, 6pm etc)
or according to the 24 hour clock (military clock) 
Avoid recording in advance.

2.Legibility

 Entries must be legible and easy to read.

 Writing must be clear.
 Very important in recording numbers and medical
terms
3.Correct Spelling

 Correct spelling is essential for accuracy

4.Permanence

 Entries should be done in dark ink.

 It helps to identify changes and allows duplication

5. Accepted Terminology

 Use commonly accepted abbreviations, symbols and

terms that are specified by the agency
6.Factual

 Descriptive objective information about what nurse

sees, hears, feels and smells.
 Use of inference without supporting data is not
acceptable.
 Vague terms like appear, seem or apparently is not
accepted.
 Include objective signs of problems.
 Subjective data is documented in client’s exact words
within quotation marks.
7.Accurate

 Use of exact measurement establishes accuracy.eg.

Intake 450ml of water than writing adequate amount
of water.
 Clients name and identifying information is written on
each page.
 Before making any entry in the chart makes sure that
it is correct.
 Chart only your observations and actions to be
accountable.

If any mistakes occur while recording, draw a

line through it and write above or next to
original entry with your initials or name. Do not
erase, blot or use correction fluids.
8.Appropriateness

 Record information's pertaining to the client health

problems& care only.
9.Completeness
 Document all necessary information's.
 It should give a clear picture of what took place
Complete pertinent assessment data such as vital
signs, wound drainage, client complaints, which was
notified and what interventions are carried out are
recorded.
10. Current
 Timely entries are must Keeping record at bed side
may facilitate immediate documentation.
11. Conciseness

 (BRIEVITY)Recording need to be brief as well as

complete to save time in communication.
 Client’s name and the word client can be omitted E g.
“perspiring profusely. Respiration shallow. 28/mt ”
Use accepted abbreviations18. 13

12. Organized

 Information should have logical manner. E g.

description of pain, nurses assessment and
interventions and the client response
 This helps in preventing any omission of information.
Easy to read.
13. Signature

 Each recording is signed by the nurse Signature

includes the name and the title in computerized
charting nurse will have his or her own code.
14. Confidentiality
 All the client’s record are confidential files
 The information in the chart is personal as well as
legal.
 Record shouldn't be copied without the permission of
the client
 Nurse should not allow any outsiders to verify the
client record.
 Consequences of Inadequate
Documentation

 Fragmented care
 Repetition of tasks
 Delayed therapy
 Omitted therapy
 Delayed recovery
Types of documentation

Records
 Record is a permanent written communication that
documents information relevant to a client’s health
care management, e.g. a client chart is a continuing
account of client’s health care status and need.
 Conduct training and research work
 Assess health problems.
Methods

1. Source Oriented traditional client record

2. Problem Oriented Medical Record
(POMR)
3. PIE Charting (Problem, intervention,
Evaluation)
4. Focus charting
5. Charting by exception (CBE)
Method of documentation

1. Source Oriented traditional client record

 It is the client chart, information about a particular
problem is distributed throughout the record
 e.g. if a patient had left hemiplegia ,data about this
problem must be found in the physician history
sheet, in the nurses notes, in the physical therapist
record and in the social service record
A. Components of a source oriented record
 Admission sheet (face) – initial nursing assessment
– graphic record – daily care record – special flow
 sheets - medication record –nurse’s & physical
examination findings – physician order sheet –
physician progress notes – consultations record –
diagnostic reports –– referral summery – patient
consent.

Disadvantage is that information about a particular client

problem is scattered throughout the chart, so it is difficult to find
chronological information on a client problems and progress .

Advantage These records are convenient because care

provider from each discipline can easily locate the forms on
which to record data & it is easy to trace the information
specific to one’s discipline.
2.Problem Oriented Medical Record (POMR)

 In the POMR, established by Lawrence weed

in the1960s, data arranged according to the
problems the client has rather than the source
of information.

 Soap Used For Problem-Oriented Charts

S – Subjective. What Pt. Tells You
O– Objective. What You Observe, See
A – Assessment. What You Think Is Going On
Based On your Data.
P – Plan. What You Are Going To Do.
Advantages:
 Encourage collaboration.
 The problem list in the front of the chart alerts
caregivers to the client and make it easier to track the
status of each problem.

Disadvantage:
 Caregivers differ in their ability to use the required
charting format.
 It takes constant vigilance to maintain up to date
problem.
 It is inefficient because assessment &interventions
repeated to more than one problem list.
 Basic component of POMR
 Database – problem list – plan of care – progress
notes.
In addition, flow sheets & discharge notes added to the
record as needed

3. PIE Charting (Problem, intervention, evaluation)

 Similar to SOAP charting both are problem- oriented
PIE comes from the Nursing Process; SOAP comes
from a Medical Model.

P Problem
I -Intervention
E –Evaluation
Advantages:
 The PIE system eliminate the traditional care plan and
incorporate an ongoing care plan into the progress
notes. The nurse doesn’t have to create and update and
separate plan.

Disadvantages:
 Must review all the nursing notes before giving care
to determine which problems are current and which
interventions were effective.
4. Focus charting:
 A method of identifying and organizing the narrative
documentation of all client concerns.
 Uses a columnar format within the progress notes to
distinguish the entry from other recordings in the narrative
notes (Date & time; Focus; Progress note).

The progress notes are organized into; Data (D),

Action (A), • Response (R)

 Example of focus charting • Date & Time Focus: Progress

notes: • 09./5/.2019 Acute pain related to surgical incision
D: Patient reports pain as 7/10 on 0 to 10 scales. • A: Given
morphine 1mg IV at 2335. • R: Patient reports pain as 1/10
at 2355.
 Advantage
 Provide a holistic perspective of the client & the client
needs.
 Provide a nursing process framework for the progress notes
DAR.
 You doesn’t need to have all three categories or recorded in
ordered.

5. Charting by exception
Uses flow sheet emphasis on abnormal (what is
abnormal for this patient. Although it may be
abnormal for the “normal” person, if it is
abnormal for your patient on a consistent basis, it
is no longer considered an “exception.
Forms for Recording Data

1. The Carded

 Is used as a reference throughout the shift and during

change- of-shift reports.
 Client data (e.g. name, age, admission date, allergy).
 Medical diagnoses and nursing diagnoses.
 Medical orders, list of medications
 Activities, diagnostic tests, or specific data on the pt.
 Provides a concise method of organizing and
recording data about a client, making information
recording data about a client, making information
readily accessible to all members of the health team.
2. Flow Sheets

 The information on flow sheets can be formatted to

meet the specific needs of the client.
 (e.g.: graphic sheets for vital signs, intake & output
record, skin assessment record)

3. Nurses’ Progress Notes

 Used to document the client’s condition, problems

and complaints, interventions, responses,
achievement of outcomes.
4. Discharge Summary

 Client’s status at admission and discharge.

 Brief summary of client’s care.
 Interventions and education outcomes.
 Resolved problems and continuing need.
 Referrals.
 Client instructions.
 REPORT
1. DEFINITION

 Reports are oral or written exchanges of

information shared between care givers of
workers in a number of ways.
 A report Summarize the service of the
personnel and of the agency

2. PURPOSES of REPORT

 Report is an essential tool to communication.

  To show the kind and amount of services
rendered over a specific period.
 To illustrate progress in teaching goals.
 As an aid in studying health condition.
 As an aid in planning.
 To interpret the services to the public and to
the other interested agencies.

3.Criteria for Good Report

 Made promptly.
 Clear, concise, and complete.
 If it is written all pertinent, identifying data
are included-the date and time, the people
 concerned, the situation, the signature of the
person making the report.
 It is clearly stated and well organized
 Important points are emphasized.
 In case of oral reports they are clearly
expressed and presented in an interesting
manner.
Types OF REPORT

 Change-of-shift reports
 Transfer and discharge reports
 Telephone report
 Incident report
Change-of-shift reports:
 The face-to-face report permits the listener to
ask questions during the report; written and
tape-recorded reports are often briefer and less
time consuming.
 Reports are sometimes given at the bedside, and
clients as well as nurses may participate in the
exchange of information.

Transfer discharge reports and:

 Nurse report a summary of patient’s condition
and care when transferring patients from one
unit or institution or agency to another (e.g.,
from the post anaesthesia care unit to a surgical
floor) and when discharging patients. The nurse
 making the report should concisely summarize
all the patient data that care givers nee to
provide immediate care.

Telephone report:
 Telephones can link health care professionals
immediately and enables nurses to receive and
give critical information about patients in a
timely fashion.
 Reporting Telephone Reports and Orders
Report transfers, communicate referrals, obtain
client data, solve problems, and inform a
physician and/or client’s family members
regarding a change in the client’s condition.
  Telephone orders are documented in the
nurses’ progress notes and the physician
order sheet

Incident report:
 It is also a variance or occurrence report, is a
tool used by health care agencies to document
the occurrence of anything out of the ordinary
that results in or has the potential to result in
harm to a patient, employee, or visitor.
 These reports are used for quality improvement
and shouldn’t be used for disciplinary action
against staff members.
 They are a means of identifying risks.
  Incident reports improve the management and
treatments of patients by identify high-risk
patterns and initiating in-services programs to
prevent future problems.

While incident reporting, the following

points are to be kept in mind:
 The nurse who witnessed the incident or
who found the patient at the time of incident
should fill the report.
 The report should be completed as soon as
possible.
 The nurse describe in concise what
happened specifically objective terms.
 The nurse doesn’t interpret or attempt to
explain the cause of the incident.
 The nurse objectively the clients, conditions
when the incident was discovered.
 Any measures taken by the nurse, other
nurses, or doctors at the time of the incident
are reported.
 No nurse is blamed in an incident report.
 The report is submitted as soon as possible
to the appropriate authority.
 The nurse should never make a
photocopy of the incident report.
The nurse includes the following
information in an incident report:
 Identify the client by name, initials, and hospital
or identification number.
 Give the date, and place of the incident.
 Describe the facts of the incident. Avoid any
conclusions or blame. Describe the incident as
you saw it even if your impressions differ from
those of others.
 Incorporate the client's account of the incident.
 State the client’s comments by using direct
quotes.
 Identify all witnesses to the incident.
 Identify any equipment by number and
any medication by name and dosage.
Electronic Documentation

Definition of electronic Documentation:

It allows nurses to use computers to restore
client data (client assessment, medication
administration, client teaching, progress notes,
care plan updating, and client acuity).
Guidelines of using of electronic
documentation:
 Must be comprehensive, accurate, timely, and
clearly identify who provided what care.
 Never reveal or allow anyone else access to your
personal identification number or password as
these are, in fact, electronic signatures.
 Inform your immediate supervisor if there is
suspicion that an assigned personal
identification code is being used by someone
else.
 Change passwords at frequent and irregular
intervals (as per agency policy).
 Choose passwords that are not easily
deciphered.
 Log off when not using the system or when
leaving the terminal.
 Maintain confidentiality of all information.
Advantage:
 Different electronic documentation.
 Facilitate quickly.
 Providers at different locations.
 Access by different providers at the same
time.
 Increases accuracy and legibility.
 Reduced error or omission.
 Enhance quality of documentation.
 Improve communication between health
care providers
Disadvantage
 Computer downtime: systems can crash or
break down, making information
temporarily unavailable.
 Computerized systems can threaten a
patient’s right to privacy, Confidentiality
may be a problem.
 Cost: includes the cost of software and
hardware, cost of the training, and cost of
supervisory involvement during the
transitional period of change.
 Role of nurse manager in
documentation:
 A nurse manager must assume responsibility for
ensuring complete and accurate documentation.
 Assist staff in adhering to both clinical and
documentation standards.
 Provide continuing education, professional feedback,
and input into policy and documentation-system
changes whenever possible.
 Must ensure that nursing staff comply with up-to-date
standards, it is equally important to ensure that they
document that compliance accurately and completely.
 Ensure that the nursing staff follows the established
policies of the organization.
 Emphasizing the importance of documentation
through written guidelines, policies, job descriptions,
and performance appraisals.
Thank
you…