Documentation NUR 210

STANDARDS OF NURSING PRACTICE 1955: ANA defined nursing practice 1965: ANA Committee on Education’s position paper 1980: Congress for Nursing Practice—definition of nursing 1991: ANA Standards of Clinical Practice 1999: Revised wording

ANA Standards of Care Assessment Nursing Diagnosis Planning Collection of patient health data Nursing Diagnosis Analysis of data and identify outcomes Planning Develop plan of care Implementation Implements the plan Evaluation Evaluates the progress toward attainment of outcomes

Methods of Communication Among Staff Members Oral and Written Walking Rounds Discussions Consultants Medical Record

Purpose of the Medical Record Communication Financial Billing Education Assessment Research Auditing and Monitoring Legal Document

Documentation Anything written or printed that is relied on as a record of proof for authorized persons. Comprehensive description of the client’s health status and needs, as well as the services provided for the client’s care.

Guidelines for Documentation Factual Basis Accuracy Completeness Currentness Organization Confidentiality Pertinent Data

Methods of Recording Narrative Problem Oriented Medical Records SOAP or SOAPIE PIE or APIE Source Records Charting by Exception Focus Charting Case Management/Critical Pathways Computerized

Documentation Procedures What procedure was done When it was performed How it was performed How well the patient tolerated it Adverse reactions to the procedure, if any

Eight Legal Hazards Incident reports Informed concent Advance directives Patients who refuse treatments Documenting for unlicensed personal Using restraints Patients who request to see their charts Patients who leave against medical advise