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Kingdom of Saudi Arabia General Nursing Administration DOCUMENTATION Nursing Documentation – a written record of data, information which the nurse writes about the patient to communicate with other members of the health team, who are involved in the patient care. Purposes of Documentation: 1. Communication - The record serves as the vehicle by which different health professionals who interact with a client communicate with each other. This prevents fragmentation, repetition, and delays in client care. 2. Planning Client Care - Each health professionals uses data from the client’s record to plan care for that client. Nurses use baseline and on – going data to evaluate the effectiveness of the nursing care plan. Ex. A physician may order an antibiotic after establishing that the client’s temperature is high and lab. test reveals certain microorganism. 3. Quality Management / Auditing - An audit is a review of client records to determine if particular health agency is meeting its particular standards. 4. Research - The information contained in a record can be a valuable source of data for research. The treatment plans for a number of clients with same health problems can yield information helpful in treating other clients. 5. Education - A record can frequently provide a comprehensive view of the client, the illness, effective treatment strategies, and factors that affect the outcome of the illness. 6. Legal Purpose - The client’s record is a legal document and is usually admissible in court as evidence. It serves as a legal document of the client’s health status and care received. General Guidelines for Documentation: 1. Date and Time - is essential not only for legal reasons but also for client safety. Record the time according to the 24 –hour clock (military clock ), which avoids confusion about whether a time was AM or PM. 2. Timing - documenting should be done as soon as possible after an assessment or intervention. No recording should be done before providing nursing care. Record all medications at the time they are given and procedures, treatments, and assessment as soon as possible after their completion. When the client status changes, document immediately. 3. Legibility - all entries must be legible and easy to read to prevent interpretation errors. Ex. The term dysphasia ( difficulty speaking ) could be mistaken for dysphagia ( difficulty swallowing ) 4. Permanence - all entries on the client’s record are made in dark ink so that the record is permanent and changes can be identified. Dark ink reproduces well on microfilm and in duplication processes. 5. Accepted Terminology - use only commonly accepted abbreviations, symbols, and terms that are specified by the agency. Abbreviations can lead to misunderstandings. For example, D/C may mean “ discharge” or “ discontinue”. 6. Correct Spelling - correct spelling is essential for accuracy in recording. If unsure how to spell a word, look it up in a dictionary or other resource book. Incorrect spelling gives a negative impression to the reader and, thereby, decreases the nurse’s credibility. 7. Signature - each recording on the nursing notes is signed by the nurse making it. The signature includes complete name or initial of first name followed with family name. Example: FATMA HAWSAWI M. PERALTA 8. Accuracy – The client’s name and identifying information should be written on each page of the clinical record. Entries must be accurate and correct. Accurate notations consist of facts or observations rather than opinions or interpretations. For example: 1. Write the client “ refused medication” (fact) than to write that the client “ was uncooperative” ( opinion ). 2. Write that the client “was crying” (observation) is preferable to noting that the client “ was depressed” ( interpretation). 3. A wound should be described as “ 3 cm by 1 cm” rather than “ small”. MISTAKEN ENTRY: When a recording mistake is made, draw a line through it and write the words mistaken entry above or next to the original entry, with your name. Do not erase, blot out, or use correction fluid. The original entry must remain visible. Avoid writing the word “ error” when a recording mistake has been made. Some believe that the word error can lead to the assumption that a clinical error has caused a client injury. DON’T LEAVE BLANK SPACES: If a blank appears in a notation, draw a line through the blank space so that no additional information can be recorded at any other time or by any other person, and sign the notation. 9. Sequence / Organization - documents events in the order in which they occur; for example, record assessments, then the nursing interventions, and then the client responses. Their must be chronological flow of information about patient care according to time and procedures completed, with the patient’s reaction documented. 10. Appropriateness - record only information that pertains to the client’s health problems and care. Recording irrelevant information may be considered an invasion of the client’s privacy. 11. Completeness - information that is recorded needs to be complete and helpful to the client and heath care professionals. Nurses’ notes need to reflect the nursing process. Records all assessments, dependent and independent nursing interventions, client problems, client comments and responses to interventions and tests, progress toward goals, and communication with other members of the health team. Care that is omitted because of the client’s condition or refusal of treatment must also be recorded. Document what was omitted, why it was omitted, and who was notified. Do not assume that the person reading your charting will know that a common intervention (e.g. turning ) has occurred because you believe it to be an “ obvious” components of care. 12. Conciseness - recordings need to be brief as well as complete to save time in communication. The patient’s name and the word patient is omitted. For example, write “Perspiring profusely”. 13. Legal Prudence - accurate, complete documentation should give legal protection to the nurse, the client’s other caregivers, the health care facility, and the client. Admissible in court as a legal document, the clinical recordprovides proof of the quality of care given to a client. Documentation is usually viewed by juries and attorneys as the best evidence of what really happened to the client. Complete charting, for example, using the steps of the nursing process as a framework, is the best defense against malpractice.
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