Documentation
NUR101
Lecture #5
Fall 2008
K. Burger, MSED, MSN, RN, CNE
PPP by S. Niggemeier, MSN, BSN, RN
Purpose of Documentation
 Supports Nsg
actions indicates
client’s condition
 Primary
communication
tool
 Legal protection
 Reimbursement
 Education
 Quality
Assurance
 Research
 Historic and
legal document
 Decision analysis
Types of Documentation
 Nurses Notes
 Flow sheets
 Graphics
 Nursing Care Plans
 Caremaps
 Critical Pathways
 Computer charting
Methods of Documentation
 Traditional (source
oriented client record)
 Problem Oriented Medical
Record (POMR)
-SOAP
-PIE
-Focus DAR
 Charting by exception
Documentation
 NN (nurses notes) best assessment
of pt. care.
Most used section of the medical record in legal cases
 Documentation or Charting is a skill
 Record of pt.’s condition, activities
and events that occurred to the
PATIENT.
 Not a diary of your activities.
 Includes Subjective & Objective
info
Documentation
 Chart facts, not your opinion
 Use quotations if pt. said it.
 Be specific!! Using nonspecific terms
implies doubt about your knowledge.
i.e. appears/seems/tolerated well etc.
 In most cases when care or
observations are not charted it means it
wasn’t done
 ABC’s: Accuracy/Brevity/Completeness
Guidelines for Documentation:
Content
 Focus on pt.
 Not a novel or essay
 Use short sentences
 Abbreviations
 Symbols
 Don’t need to use word pt.
Guidelines for Documentation:
Timing
 Chart as soon as possible after
care/observations
 NEVER chart what you plan to do
 Date & time each entry in the margin
Guidelines for Documentation:
Format
 Use forms as per agency policy(i.e. flow
sheets, graphic sheet, NCP, progress
notes)
 Follow agency guidelines regarding color
ink, approved abbreviations, format of
time (i.e. military/standard)
 Write LEGIBLY-questionable info implies
doubt suggests you lack reasonable
knowledge
 NEVER skip lines!!
 Use correct grammar/spelling
Guidelines for Documentation:
Accountability





Record is permanent
Sign full name and title
No erasures
Do Not write ERROR for a mistake
Single line thru mistake, print
“Mistaken Entry” or ME (if
acceptable) above or next to
mistake, enter correction, initial &
date per policy
Guidelines for Documentation:
Confidentiality
 Students only use patient initials on
assignments
 Only caregivers need to know info in
chart
 Follow facility policy for pt. review of
chart.
Other Guidelines for
Documentation
 Hospitalscomputers
 Home carelaptops
 Telephone
orders