DOCUMENTATION

Outline of Documentation
in Healthcare:
0 Introduction to Documentation

1
0 Purpose of Documentation

2
0 Legal and Practice Standards

3
0 Principles of Effective Documentation

4
0 Conclusion

5
 - Enhance Communication

- Maintain Accountability

- Facilitate Education

Objectives of
Documentation in Healthcare
- Support Research Efforts

- Ensure Legal Compliance

- Improve Reimbursement Procedures

 Easy to change colors.
You can simply impress your audience and add a unique zing and appeal to
your Presentations. Get a modern PowerPoint Presentation that is
beautifully designed. Easy to change colors, photos and Text.

DOCUMENTATION :
the process of creating, maintaining, and organizing written (or digital) records that convey
information, evidence, and data about an event, process, or subject
WRITTEN EVIDENCE OF:

The interactions between and among health

care professionals, clients, their families, and
health care organizations.

The administration of tests, procedures,

treatments, and client education

The results of, or client’s response to,

diagnostic tests and interventions
 Purposes of Documentation

Professional responsibility Research

Accountability Satisfaction of Legal

and Practice standards
Communication
Reimbursement
Education
 Purposes of Documentation

as Communication as Education as Research as Reimbursement

method that confirms the The medical record can be The medical record Accreditation and
care provided to the client used by health care is a main source of reimbursement agencies
students as a teaching tool data for clinical require accurate and
▪It clearly outlines all research. thorough documentation
important information ▪It is a main source of data of the nursing care
regarding the client for clinical research. rendered and the client’s
response to interventions.
 as Legal & Practice Standards
Nurses are responsible
for assessing and
documenting that the
client has an
understanding of
treatment prior to Informed Consent Advanced Directives
intervention. A competent client’s ability to make Written instructions about a
health care decisions based on full client’s health care preferences
disclosure of the benefits, risks, regarding life-sustaining
and potential consequences of a measures. (e.g. living will and
▪Two indicators of the recommended treatment plan. durable power of attorney for
above are Informed health care).
Consent and Advance ▪The client’s agreement to the
Directives. treatment as indicated by the ▪Allows clients, while competent,
client’s signing a consent form. to participate in end-of-life
decisions.
 Principles of Effective Documentation

Elements of nursing process needed to be made evident in documentation include:

Assessment. Implementation.
Nursing Diagnosis. Evaluation.
Planning and outcome identification. Revisions of planned care.
 Elements of Effective Documentation
To ensure effective documentation, nurses should:

1 2 3 4 5

Employ factual Write legibly Use only authorized Use a common Document
and time- and neatly abbreviations and vocabulary accurately and
sequenced symbols. completely,
organization. including any errors
Methods of Documentation
Narrative Charting

Source-oriented charting

Problem-oriented charting

PIE charting

Focus charting

Charting by exception

Computerized documentation
Methods of Documentation
Narrative Charting :

▪This traditional method of nursing

documentation takes the form of a story written
in paragraphs.

▪Before the advent of flow sheets, this was the

only method for documenting care.

Source-Oriented Charting

▪ A narrative recording by each

member (source) of the health care
team on separate records.
Methods of Documentation
Problem-Oriented Charting

▪Focuses on the client’s problem and employs a

structured, logical format called SOAP charting:

▪S: Subjective data (what the client states)

▪O: Objective data (what is observed/inspected)
▪A: Assessment
▪P: Plan

PIE Charting

▪PROBLEM
▪INTERVENTION
▪EVALUATION
Methods of Documentation
Focus Charting

▪A documentation method that uses a

column format to chart data, action, and
response (DAR).

Charting by Exception

▪A documentation method that requires the

nurse to document only deviations from
pre-established norms.
 Computerized Documentation: Advantages
Decreased documentation time.

Increased legibility and accuracy.

Clear, decisive, and concise words.

Statistical analysis of data.

Enhanced implementation of the nursing process.

Enhanced decision making.

Multidisciplinary networking.
▪
Critical Pathways
A comprehensive, standard plan of care for
specific case situations.
The pathway is monitored to ensure that
interventions are performed on time and
client outcomes are achieved on time.

Forms for Recording Data

Kardex
Flow Sheets
Nurse’s Progress Notes
Discharge Summary
 Forms for Recording Data

Karde Flow Nurse’s Progress Discharge

x Sheets Notes Summary

Your Text Here

You can simply impress
your audience and add
a unique zing and
appeal to your
Presentations.
Kardex Client data (name,
age, marital status,
religious preference,
summary worksheet physician, family
reference of basic contact).
information that
traditionally is not
Medical diagnoses:
part of the record.
Usually contains: listed by priority.

Allergies.

Medical orders (diet,

IV therapy, etc.).

Activities permitted.
Flow Sheets
Vertical or horizontal Client teaching.
columns for recording Use of special
dates and times and equipment.
related assessment IV Therapy
and intervention
information. Also
included are notes
on:
Nurse’s
Progress Client’s condition,
problems, and
Notes complaints.

Interventions.
Used to document:
Client’s response to
interventions.

Achievement of
outcomes.
 Discharge Intervention and
education outcomes.
Summary
Resolved
Highlights client’s illness
and course of care. problems and
Includes: continuing care
needs.
Client’s status at
Client instructions
admission and
discharge. regarding
medications, diet,
food-drug
Brief summary of
interactions, activity,
client’s care. treatments, follow-up
and other special
needs.
 Trends in Documentation
1) Nursing Minimum Data 5) Summary Reports
3) Nursing Intervention
Set The outlining of information
The elements that should be Classification
A comprehensive standardized pertinent to the client’s needs
contained in clinical records as identified by the nursing
and abstracted for studies on language for nursing
interventions organized in a process.
the effectiveness and costs of
three-level taxonomy. Commonly given at end-of-
nursing care. Focuses on:
shift.
Demographics. 4) Nursing Outcomes
Service. Classification
Nursing care. A classification system that 6) Walking Rounds
comprises 190 outcome labels A reporting method used when
2) Nursing Diagnoses and corresponding definitions,
A clinical judgment about the members of the care team
measures, indicators, and walk to each client’s room and
individual, family, or community
references. discuss care and progress with
responses to actual or potential
health problems or life each other and with the client.
processes.
. 7) Telephone Reports and
8) Incident Reports
Orders
The documentation of
Telephone communications are
any unusual occurrence or
another way nurses:
accident in the delivery of
client care, such as falls or
Report transfers. medication errors.
.
Communicate referrals.
Obtain client data.
Solve problems.
Inform a client’s family
members regarding a change in
client’s condition
‫‪Thank you‬‬
‫باشراف ‪:‬محمد ا&شاقبة‬
‫احمد بني‬ ‫احمد‬
‫عيسى‬ ‫الجرايدة‬