Documentation

• Documentation


  Written evidence of interactions between health professionals, clients, their families, and health care organizations; administration of tests, procedures, treatments and client education; specific procedures, treatments, management or interventions; client education and response to diagnostic tests and interventions
• Primary reasons for documentation

  • Professional responsibility
  • Accountability
  • Communication, education, research, satisfaction of legal and practice standards, and reimbursement
• Nurses' progress notes


  • Logical (on-time and actual situation), focused (patient care and nursing management/intervention), and relevant to care; represent each phase of the nursing process (ADPIE)
• Nursing documentation based on the nursing process facilitates effective care because client needs can be traced from assessment, through identification of the problems, to the care plan, implementation and evaluation
• Elements of effective documentation


  • Accurate, complete and objective, including any errors
  • Note date and time
  • Use appropriate forms
  • Identify the client
  • Write in ink
  • Use standard abbreviations
  • Spell correctly
  • Write legibly
  • Correct errors properly
  • Write on every line
  • Chart omissions
  • Sign each entry
• Narrative charting


  Traditional, chronologic account written in paragraphs, narrating all the patient's responses, signs and symptoms, and the nursing process
• Problem-oriented charting


  Structured, logical format using SOAP, SOAPIE, or SOAPIER
• Focus charting


  Use of a column format to chart data, action and response (DAR); usually focused on a nursing diagnosis, sign/symptom, acute change, or special need
• Documentation


  Written evidence of interactions between health professionals, clients, their families, and health care organizations; administration of tests, procedures, treatments and client education; specific procedures, treatments, management or interventions; client education and response to diagnostic tests and interventions
• Primary reasons for documentation

  • Professional responsibility
  • Accountability
  • Communication, education, research, satisfaction of legal and practice standards, and reimbursement
• Nurses' progress notes


  • Logical (on-time and actual situation), focused (patient care and nursing management/intervention), and relevant to care; represent each phase of the nursing process (ADPIE)
• Nursing documentation based on the nursing process facilitates effective care because client needs can be traced from assessment, through identification of the problems, to the care plan, implementation and evaluation
• Elements of effective documentation

  • Accurate, complete and objective, including any errors
  • Note date and time
  • Use appropriate forms
  • Identify the client
  • Write in ink
  • Use standard abbreviations
  • Spell correctly
  • Write legibly
  • Correct errors properly
  • Write on every line
  • Chart omissions
  • Sign each entry
• Narrative charting


  Traditional, chronologic account written in paragraphs, narrating all the patient's responses, signs and symptoms, and the nursing process
• Problem-oriented charting (POMR)


  Structured, logical format using SOAP, SOAPIE, or SOAPIER
• Focus charting


  Use of a column format to chart data, action and response (DAR); usually focused on a nursing diagnosis, sign/symptom, or acute change in patient's condition