1. Nursing Documentation Overview
Chapter 2
Nursing Documentation Overview
McGraw-Hill
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

2. Chapter 2 Content
2.1 Role of documentation in nursing practice 2.2 Purposes of documentation 2.3 Documentation methods 2.4 Medication administration using an electronic Medication Administration Record (eMAR) 2.5 Nursing diagnoses, NOC, and NIC

3. LO 2.1 Role of Documentation in Nursing Practice

4. LO 2.1 Role of Documentation in Nursing Practice
Communication
Key to preventing medical errors
Promoted by documentation by all disciplines
Assessments
Treatments
Diagnostic testing
Preparation for discharge
Trend toward use of EHR to enhance communication

5. LO 2.1 Role of Documentation in Nursing Practice
Advantages of EHRs
Enhanced quality of documentation
Promotion of safe, effective patient care
Readily accessible information
Elimination of illegible handwriting
Automatic alerts
Decision support
Reduction in duplication of diagnostic testing

6. LO 2.1 Role of Documentation in Nursing Practice
Concerns with Use of EHRs
Confidentiality/HIPAA
Power outages
Computer “crashes”
Computer viruses altering data

7. LO 2.2 Purposes of Documentation

8. LO 2.2.Purposes of Documentation
Prevention of medical errors
Communication with other healthcare providers
Demonstrate the delivery of care
Ensure appropriate reimbursement
Demonstrate adherence to accreditation standards
Provide evidence in legal proceedings
Promote knowledge development through research

9. LO 2.2.Purposes of Documentation
Three ‘Cs’ of Documentation
Comprehensive
Concise
Clear

10. LO 2.2.Purposes of Documentation
Characteristics of Good Documentation
Factual
Accurate
Complete
Current
Organized
Legible
Secure

11. LO 2.2.Purposes of Documentation
Types of Documentation Errors
Errors of omission
Inaccurate documentation
Incomplete documentation

12. LO 2.3 Documentation Methods

13. LO 2.3 Documentation Methods
Narrative
Charting by exception (CBE)
Source oriented
Focus charting (DAR)
Critical pathway / caremap
Problem-oriented
PIE
SOAP
SOAPIER

14. LO 2.3 Documentation Methods
PIE
Problem
Intervention
Evaluation

15. LO 2.3 Documentation Methods
SOAP
Subjective
Objective
Assessment
Plan

16. LO 2.3 Documentation Methods
SOAPIER
Subjective – patient verbalization
Objective – measurable data
Assessment – nursing diagnosis
Plan – desired outcomes
Intervention – nursing actions
Evaluation – patient response
Revision/resolution – modifications of plan

17. Nursing Process SOAPIER Subjective Data Objective Data Assessment
Nursing Diagnosis
Plan
Nursing Outcomes
Intervention
Nursing Intervention
Evaluation
Revision

18. LO 2.4 Electronic Medication Administration Record (eMAR)

19. LO 2.4 Electronic Medication Administration Record (eMAR)
Medication Administration = Key nursing function

20. LO 2.4 Electronic Medication Administration Record (eMAR)
Rights of Medication Administration
Right patient
Right medication
Right time
Right dose
Right route
Right assessment
Right education
Right evaluation
Patient’s right to
Right documentation

21. LO 2.4 Electronic Medication Administration Record (eMAR)
Documenting Medication Administration
Medication name
Medication dosage
Medication route
Medication frequency
Date and time of administration
Signature of nurse who administers

22. LO 2.4 Electronic Medication Administration Record (eMAR)
Withholding Medications
Reasons for withholding
Patient NPO
Patient nauseated/vomiting
Patient condition contraindicates
Patient refusal
Document when held
Prevents appearance of error of omission
Indicates reason for withholding
Follow facility policy

23. LO 2.4 Electronic Medication Administration Record (eMAR)
Benefits of eMars
Reduction in medication errors
Efficient tracking of medications
User-friendly
Interface with bar code systems where available

24. 2.5 Nursing Diagnoses, NOC, and NIC

25. 2.5 Nursing Diagnoses, NOC, and NIC
Standardized Nursing Language
Unified language for documenting care
Allows comparison of care across settings
Communicates
Quality
Effectiveness
Value of nursing care
Purpose – accurate, legal, reimbursable documentation

26. 2.5 Nursing Diagnoses, NOC, and NIC
North American Nursing Diagnosis Association-International (NANDA-I)
Nursing diagnosis classifications
Reflect nursing needs of individuals
Guide nursing decisions
Guide nursing plans of care
Used in variety of settings
Based on assessment data

27. 2.5 Nursing Diagnoses, NOC, and NIC
Nursing Outcome Classifications (NOC)
Reflect desired outcomes of nursing care
Linked to nursing diagnoses

28. 2.5 Nursing Diagnoses, NOC, and NIC
Nursing Intervention Classifications (NIC)
Reflect nursing actions designed to help meet nursing outcomes
Linked to nursing diagnoses