UMENTATION by mikesanye


									                       Kingdom of Saudi Arabia
                    General Nursing Administration


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

     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.
             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”.


     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


      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
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
          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
  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

        Complete charting, for example, using the steps of the
         nursing process as a framework, is the best defense against

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