A nurse's documentation

Islamic University of Gaza
Faculty of Nursing
Trends And Issues
Documentation in the health record is an integral
part of safe and effective nursing practice.
Clear, comprehensive and accurate documentation
is a judgment and critical thinking used in
professional practice and provides an account of
nursing’s unique contribution to health care.
Effective communication requires to be done in a
timely manner.
Nurses should also be aware of the legislative
requirements regarding documentation that may
apply to their particular practice setting.
Effective documentation policies and practice take
into consideration who the clients are, client needs
and available resources.
Purpose of Documentation
1. Communication
Documentation is fundamentally communication
that reflects the client’s perspective on his/her health, the
care provided, the effect of care and the continuity of care.
 Effective documentation assists clients to make future
care decisions.
 Accurate documentation also reflects the effectiveness of
the care provided.
 Accurate documentation provides a reliable, permanent
record of client information.
2. Accountability
The health record demonstrates nurses’
accountability and gives credit to nurses for their
professional practice.
It is used to determine responsibility and may be
used in legal proceedings.
Legislative issues: failing to keep records as
required, falsifying a record, signing or issuing a
false or misleading statement, giving information
about a client without consent and storage and
retrieval of documentation.
3. Quality improvement
Information from the health record is often used
to evaluate professional practice during quality
improvement processes, such as performance
reviews, accreditation, legislated inspections and
board reviews (‫)األمناء‬.
Clear documentation facilitates the evaluation of
the client’s progress toward desired outcomes.
It enables nurses to identify and address areas
that need improvement.
Poor documentation provides incomplete or no
written evidence of the quality of care provided.
4. Research
Health records can be a valuable source of data
for health research.
Health records can be used to assess nursing
interventions and evaluate client outcomes, as
well as to identify care issues.
Accurately recorded information is essential to
provide accurate research data.
Through research, nurses can improve nursing
5. Funding and resource management
Data from health records can identify the type
and amount of care that clients need, the care
and services provided, and the effectiveness of
that care. Any of these factors may affect
funding and resource allocation.
Workload or client classification systems are
best derived as byproducts of client
Core Standards for Documentation
These are the minimum expectations:
nurse maintains documentation that is:
Clear, concise and comprehensive
Accurate, true and honest;
Reflective of observations, not of unfounded
Timely and completed only during or after giving
Chronological: present a clear picture of events
Complete record of nursing care provided,
including assessments, identification of health
issues, a plan of care, implementation and
Legible and non-erasable
Using forms, methods, systems provided
A nurse’s documentation:
 Includes date and time of the care;
 Identifies who provided the care;
 Avoids meaningless phrases such as “good ” “bad
or “OK”;
 Includes what was observed and avoids
statements such as “appears to” and “seems to”
when describing observations;
 Includes signatures or initials;
 Avoids duplication of information
 Forgotten or late entries, errors and omissions,
(written with Date, time, and signature)
Documentation forms
Effective documentation forms provide a framework and
guide documentation.
To remain effective, forms often require regular review
and revision.
This review process takes into account beliefs and values
about health and organizational policy, as well as external
factors such as legislation.
For example, a facility that values client perception of
his/her health as an important aspect of a complete
assessment will have a form that includes space for this
Kardexes are a communication tool used to convey the
client’s current orders as well as upcoming tests or
surgery, diet, etc quickly and briefly.
Nurses use it to organize the care and to manage time and
multiple priorities.
Kardexes may be in paper or electronic format.
The information they contain may be erasable.
Updating Kardex information regularly
Ensuring that temporary worksheets are shredded when
no longer in use
ensuring that relevant information on a Kardex is
captured in the permanent health record
Care Plans
Care plans are written outlines of care for individual
They are part of the permanent health record.
Effective care plans are up-to-date and clearly identify
the needs and wishes of the client.
Individualizing care plans to meet the needs and wishes
of individual clients
Monitoring strips
All relevant assessment data needs to be retained in the
health record, including monitoring strips, such as
cardiac, fetal, thermal or blood pressure testing.
Documenting on the monitoring strip the client’s name
and/or identification code, and the date and time.
Advocating to have strips retained as part of the
permanent record
Documentation content
Documenting the assessment of a client includes
recording the subjective and objective data.
Objective data can be observed (e.g., swelling, bleeding,
crying) or measured (e.g., heart rate, blood pressure,
Subjective data such as statements or feedback from the
Subjective data are clearly identified as such by using
quotation marks or other marks to distinguish it from
objective data.
Third–party information
Nurses may obtain relevant information about a client or
an incident from another person, such as the client’s
family member (e.g., the mother of a pediatric client) or
Documentation methods
Some agencies may combine elements of different
documentation methods and formats to document care
Regardless of the method, the health record must present
a clear picture of the nurse’s assessment, actions and
Common methods include charting by exception, focus
charting, SOAP/ SOAPIER and narrative documentation.
May be Paper or Paperless (Electronic health records)
Do's and Don'ts of Nursing Documentation
Check that you have the correct file before you begin
Make sure your documentation reflects the nursing
Write legibly.
Chart the time you gave a medication, the administration
route, and the patient's response.
Chart precautions or preventive measures used, such as
bed rails.
Record each phone call to a physician, including the
exact time, message, and response.
Chart patient care at the time you provide it.
If you remember an important point after you've
completed your documentation, chart the information
with a notation that it's a "late entry." Include the date
and time of the late entry.
Document often enough to tell the whole story.
 Don't chart a symptom, such as "c/o pain," without also
charting what you did about it.
Don't alter a patient's record - this is a criminal offense.
Don't use shorthand or abbreviations that aren't widely
Don't write imprecise descriptions, such as "a large
 Don't chart what someone else said, heard, felt,
or smelled unless the information is critical. In
that case, use quotations and attribute the remarks
Don't chart care ahead of time - something may
happen and you may be unable to actually give
the care you've charted. Charting care that you
haven't done is considered fraud (deception ‫)الغش‬.
Thank you………………..