Nurse Caring Concepts 1A
Nursing Documentation &
Introduction to the
Nursing Process
Week 4 September 8, 2003
Purpose of Client Record
• Communication
• Assessment
• Quality Assurance
• Reimbursement
• Legal Documentation
• Research
• Education
Principles of Charting
• Accuracy
• Completeness
• Conciseness
• Objectivity
• Timeliness
• Legibility
1
Common Abbreviations
• Learn those commonly used
• Each facility has own list of approved
• Don’t use unfamiliar abbreviation unless
you know it is approved
• When in doubt, spell it out
General Medical Record Documents
• Face Sheet
• Admission Consent Form
• Medical History & Physical Examination
• Physician Orders
• Physician Progress Report
General Medical Record Documents
• Laboratory Reports
• Radiology Reports
• Healthcare Team Progress Notes: Social
Service, Dietary, PT, RT etc
• Medical Discharge Summary
• Also may be: advance directive, consult,
surgical consent, operative report etc
2
Medical Record Documents - Nursing
• Medication Administration Record (MAR)
• Nursing Admission Assessment
• Graphic Sheet
• Nursing Progress Notes
• Nursing Care Plan
Medical Record Documents-Nursing
• Flow Sheet
• Patient Education Record
• Nursing Discharge Summary Sheet
• Kardex
Nursing Flow Sheets
• Very nurse friendly!
• Rapid documentation of assessments and/or
interventions
• Normal findings & routine interventions
indicated by checkmark or simple descriptor
• May include legend for approved abbreviations
• Always used in addition to nursing progress
notes
3
Nursing Progress Notes
• Narrative documentation of patient:
– Problems, PRN medications, interventions,
response to interventions & achievement of
outcomes
• Progress note formats include: Narrative, PIE,
SOAP, CBE, Focus & others
• Formats vary per facility
Narrative Nursing Progress Notes
• Written phrases in chronological sequence
• Advantages: Easy to learn, allows any length
explanation
• Disadvantages: Time consuming; information
retrieval difficult; irrelevant information
often included, may be disorganized
Date
2/3/02
Time
1630
2/3/02
1645
Narrative Nursing Progress Notes
Lying quietly with eyes closed, easily
aroused, oriented x 3. Abd drsg dry &
intact. Denies pain but states, “I feel
nauseated” followed by emesis 50 ml
clear fluid.---------------A Torrey RNC
States he no longer feels nauseated .
Ambulates to bathroom with assist,
voided 250 ml clear, yellow urine
without dysuria. Became dizzy;
assisted back to bed and positioned
for comfort. Encouraged to cough
and deep breathe--------A Torrey RNC
4
PIE Nursing Progress Notes
• Used in conjunction with flow chart
• Entries include:
– Patient problem (P)
– Interventions used to address problem (I)
– Evaluation or outcome of intervention (E)
• Advantages: Efficient; info easy to find,
minimal redundancy
• Disadvantages: Harder to learn, RN must
organize data in PIE format
Date
2/3/02
Time
0830
PIE Nursing Progress Notes
P #1: Ineffective Breathing Pattern
related to muscle weakness & fatigue
secondary to mastectomy-------------I#1: Encouraged to deep breathe and
cough and use incentive spirometer
q 2h--------------------- -A Torrey RNC
E # 1: Demonstrates use of incentive spirometer and performs deep breathing and coughing. Produced small
amount of green-yellow sputum.
Breath sounds normal, lungs clear
per auscultation---------A Torrey RNC
Documentation & Confidentiality
• Only those with ‘need to know’ should have
access to medical record
• Never leave patient information in public area
• Do not discuss or disclose client information:
– With those not directly involved in care
– In public area or where could be overheard
– To another agency without authorization
5
!Nursing Process!
• Systematic method of planning & providing
care to patients
• Purpose: provide individualized, holistic,
effective & efficient patient care
• 6 steps in process; each building on previous
• Process circular, not linear as all steps overlap
Steps of the Nursing Process
• Assessment: data collection
• Diagnosis: data analysis to identify problems
• Outcome Identification: formulating goals &
outcomes that reflect problem resolution
• Planning: selecting nursing interventions to
assist patient to achieve goals & outcomes
• Implementation: performing interventions
• Evaluation: determining patient’s response to
interventions & degree of goal achievement
Cuesta Nursing Care Plan
PR
Nursing
Goals &
Diagnosis Outcomes
MO
Interventions
TC
Evaluation
6