DOCUMENTATION

Prepared by: Angeli Joy V. Monton, RN,RM

DOCUMENTATION
Interactions between and among health

professionals, clients, their families and health care organizations

The administration of tests, procedures,

treatments and client education

The result of clients response to these

diagnostic tests and interventions

Provides written records that reflect client care

provided on the basis of assessment data and the clients response to these interventions

PURPOSES OF HEALTH CARE DOCUMENTATION

Communication Education Research Legal and practice standards

NURSING & MIDWIFERY DOCUMENTATION

One of the biggest challenges for

midwives (or any health professional) is documentation. It is vital we thoroughly document all our assessments, actions, and discussions we have with the women we care for. Documentation provides a record for other health professionals, evidence of our care, and it tells a story for women and their families.

NURSING & MIDWIFERY DOCUMENTATION

Nursing and midwifery documentation is

a process in which the patients experience from admission to discharge is recorded in a manner which enables all clinical staff involved in the patients care to detect changes in the patients condition and the patients response to treatment and care delivery. This allows treating teams to make decisions about the best treatment options for the patient based on accurate, objective, and current information.

 Documentation is an essential part of

the nurses and midwives care of their patients but is often viewed as a burdensome activity. Uncertainty about what is required to produce quality nursing and midwifery documentation has resulted from numerous changes initiated from legal precedent or public inquiries

GUIDING PRINCIPLES OF QUALITY NURSING AND MIDWIFERY DOCUMENTATION

Guiding Principle 1

Nursing and midwifery documentation should be patient centered

Guiding Principle 2

Nursing and midwifery documentation must contain the actual work of nurses including education and psychosocial support
Guiding Principle 3

Nursing and midwifery documentation is written to reflect the objective clinical judgment of the nurse or midwife
Guiding Principle 4

Nursing and midwifery documentation must be presented in a logical and sequential manner
Guiding Principle 5

Nursing and midwifery documentation should be written contemporaneously, or as events occur

GUIDING PRINCIPLES OF QUALITY NURSING AND MIDWIFERY DOCUMENTATION

Guiding Principle 6

Nursing and midwifery documentation should record variances in care within the health care record
Guiding Principle 7

Nursing and midwifery documentation must fulfil legal requirements

LEGAL REQUIREMENTS FOR ALL NURSING AND MIDWIFERY DOCUMENTATION

Nursing and midwifery documentation must be

written legibly.
The patient must be identified by name, health

care record number and date of birth at the top of each page of nursing documentation either by an identifier, such as a sticker, or as written by the nurse.
All entries must include the date and time (using

the twenty-four hour clock) when documentation occurred and should include the signature, name and designation of the nurse or midwife.
If using medical terminology, the nurse or

midwife must be sure of its exact meaning.

LEGAL REQUIREMENTS FOR ALL NURSING AND MIDWIFERY DOCUMENTATION

Incorrect entries must not be totally obliterated. A

line should be drawn through the entry before the writer continues. The nurse or midwife should indicate that they have drawn the line through the entry by placing their initial next to the entry.
No entry concerning a patients care should be

made on behalf of another nurse or midwife.10

Before using any form of abbreviation, nurses

and midwives must ensure that the abbreviation is approved in the individual clinical setting. If there is any doubt, nurses and midwives must not use any abbreviations and write all words in full.
No blank lines are to be left between entries in

the health care record.

METHODS OF DOCUMENTATION
Narrative Charting
Traditional form Story format that describes the clients status, interventions,

treatments and response to treatments

Source-oriented charting
Narrative recording by each member of the health care team

on separate records

Problem-oriented charting
SOAPIE/R Subjective, Objective, Assessment. Problem,

Intervention, Evaluation (Revision)

PIE charting
Assessment is placed on another record

Focus charting
Method of identifying and organizing narrative

documentation to include data, action and response Not limited to clinet problems but to all concerns

Charting by Exception
Requires documentation only of deviations from pre-

established norms

Computerized Documentation