1. Documentation
NUR 111

2. Purpose of Records Communication tool for healthcare team
Legal document
Financial billing
Education
Assessment
Research
Auditing and monitoring

3. Common Forms of Documentation
Admission nursing assessment
Client care plan
Kardex or clinical worksheet
Flowsheet
Progress notes
Nursing discharge or referral summaries

4. Guidelines for Legal Documentation
Avoid words with unclear meanings
Only include facts and observations not your interpretation
Complete: assessment, interventions, client outcomes, client response, progress toward goals, care that was omitted & why, & who was notified, any communication with other disciplines
Current: done when care is provided, late entries must be noted

5. Guidelines for Legal Documentation
Organized
Appropriate: only include info relevant to current healthcare status and care being delivered
Agency policies: each entry contains date and time, legible, permanent (black) ink, correct spelling, proper terminology, contain signature

6. Pitfalls of Documentation
Writing illegibly: could lead to errors, misunderstanding
Leaving blank lines: someone could insert info at a later date
Altering someone else’s notes
Back-dating records
Correcting errors incorrectly: only draw single line through error and write “error” above it with nurse’s initials
Inserting info between lines: big no no

7. Pitfalls of Documentation
Documenting for someone else: each nurse should only document their own care and observations
Expressing opinions
Using unmeasurable terms: each entry should reflect clarity and brevity (use as few words as possible)
Failing to document communication with other healthcare members regarding client care: REMEMBER: “IF IT WAS NOT DOCUMENTED, IT WAS NOT DONE”

8. Methods of Recording
Narrative charting: normal assessment findings integrated with the documentation about the problem
Problem oriented medical record: 4 basic components; database, problem list, plan of care, and progress notes
Charting by exception: only the exception to the rule is charted: Problem (P), Intervention (I) and Evaluation (E)

9. Methods of Recording
Focus charting: clients needs that deviate from the normal; data (D), action (A) and response (R)
Critical pathways: Guidelines for client outcomes within certain groups; Ex. Clients with Pneumonia or Post-Mastectomy
Computerized charting: becoming more popular, legible records, easy to transfer client records

10. Reporting
Transfer of info from one nurse to another at shift change, or from nurse to another healthcare member
Can be written, or verbal (in person or recorded)
Change of shift report should include: Client name, age, room # & physician. Diagnosis, general condition, diet, activities permitted, scheduled diagnostic test, new orders, teaching needs, safety needs, any procedures such as dressing change, etc.
Must be careful with tape recording report; follow proper procedure to maintain confidentiality

14. Urine colors 1. straw colored urine 2. orange 3.dilute urine
4. amber/tea urine
5. cloudy urine
6. concentrated urine
7. yellow urine

18. Documentation assignment
You are taking care of the patient in the above pictures. He is a debilitated CHF/ Cor Pulmonale patient in the last stages. All of the pictures depict his physical status. Document the findings from the pictures on assessment sheets provided Continued on next slide.

19. Assignment continued This patient is on 4 Liters of Nasal O2.
His lungs sounds are crackles in lower lobes, diminished throughout. He has a productive cough at times of frothy pink sputum. Heart rate irregular and 120 bpm.
Bowel sounds present in all quadrants, hypoactive in lower quadrants.
The sacral wound measures 10cmX 8cm.

20. Assignment con’t
The sacral wound has a fetid odor, with a scant amount of green drainage. The dressing is a normal saline soak. Dressing changed at 1025.
Initial shift assessment completed at 0730.