DOCUMENTATION

IN NURSING PRACTISE

Presented By: Arhamsyah,S.Kep,Ns

 INTRODUCTION
• In modern healthcare organizations, the quality and
coordination of care depend on the communication between
different caregivers about their patients.
• Documentation is a communication tool for exchange of
information stored in records between nurses and other
caregivers.
• Quality nursing documentation promotes structured,
consistent and effective communication between caregivers
and facilitates continuity and individuality of care and safety
of patients.
 OBJECTIVES

1) Define documentation in Nursing Practice

2) State the purpose of documentation in Nursing

Practice

3) State the core principles of effective documentation

in Nursing Practice

4) Explain the importance using proper spelling and

grammar when documenting
Define documentation in Nursing Practice
Documentation
• Documentation in Nursing
Practice is anything written or
electronically generated that
describes the status of client Document
on the care or services given • Document is an integral part of
to that client (Perry, A/ G.,
Potter, P. A. , 2010) nursing practice and professional
of nursing care that takes away
from patient care.
• Nursing documentation refers
to written or electronically
client information obtained • Document is not optional.
through the nursing process,
(Association of Registered
Nurses of Newfoundland and
Labrador , 2010)
Documentation in Nursing Practice is
a written evidence of……

• the interactions between and among healthcare,

professionals, clients, their families and healthcare
organizations.

• the administration of tests, procedures, treatments and

client education.

• the results of, or clients response to diagnose test, and

intervention.
 Purpose of documentation
in Nursing Practice
1. To facilitate communication
• Nurses communicate to other nurses and care
providers, their assessment about the status of client,
nursing interventions that are carried out and the results
of these interventions through accurate documentation,
decreases the potential for miscommunication of errors.
Purpose of documentation in Nursing
Practice
2. To promote good nursing care

• Encourages nurses to access client progress and to

determine which interventions are effective, non-
effective, identify and document the changes to the
plan of care as needed

• Facilitating nursing research, all of which have the

potential to improve the quality of nursing practice
and client care.
Purpose of documentation in
Nursing Practice
3. To meet professional and legal standards

• Documentation in nursing is a valuable and important method for

demonstrating that within the nurse client relationship the nurse has
applied nursing knowledge, skills and their judgment according to
professional standards

• The nurses documentation may be used as proof or evidence in legal

proceeding such as lawsuits and disciplinary hearings through
professional regulatory bodies
 Ques:
1. Define documentation in Nursing Practice.

2. State the most important purpose of

documentation.
 Q& A
1. Define documentation in Nursing Practice.
Documentation in Nursing Practice is anything written that
describes the status of client on the care or services given to that
client.

2. State the most important purpose of

documentation.
The most important purpose of documentation is to communicate
to other members of the multidisciplinary team the patient’s
progress and general condition. D of nursing care is also used when
looking at the quality of care rendered to client.
Core principles of effective
documentation in Nursing Practice

Nursing documentation must provide an accurate and

honest account of and what events occurred as well as
identify who provided the care.

Good documentation has 6 important characteristics.

1) Factual
• Descriptive objective information about what the
nurse sees, hears, feels, smells and think

• Vague terms like seem or apparently

• Includes objective signs of problems

• Subjective data is documented in client’s exact

words within quotation marks
2) Accurate
• Use of exact measurement establishes accuracy

• e.g. Intake of 400ml of water then writing

adequate amount of water
3) Complete – be sure to include
• Condition change

• Patient’s responses especially unusual, undesired or

ineffective response.

• Communication with patient family

• Entries in all spaces on all relevant assessment form.

N/A
• Do not leave blank
4) Timely (date & time)
• Document date & time of each recording

• Record time in conventional manner (e.g. 9:00am to

6:00pm or according to the 24 hours clock)

• Avoid recording in advance (this practice is illegal

falsification of the records contributes to errors and
confusion and threatens patient safety.

• Client’s name, the word can be omitted

5) Concise
• Recording need to be brief as well as complete to
save time and communication
6) Legible

• Using black pen, clear enough to be

read, readable particularly handwriting

• Any mistakes occur while recording, draw a line

through it and write above or next to original entry
with your initial or name.
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Core Standards for Documentation

These are the minimum expectations:
• nurse maintains documentation that is:
• Clear, concise and comprehensive
• Accurate, true and honest;
• Relevant;
• Reflective of observations, not of unfounded conclusions
• Timely and completed only during or after giving care
• Chronological: present a clear picture of events
 19

• Complete record of nursing care provided, including

assessments, identification of health issues, a plan of
care, implementation and evaluation
• Legible and non-erasable
• Permanent
• Retrievable
• Confidential;
• Client-focused;
• Using forms, methods, systems provided
 20
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)
• Draw a line through the blank space so that no
additional information can be added.
RUQ : right upper quadrant
LUQ : left upper quadrant
 The importance of using
proper Spelling and grammar
of documentation in
Nursing Practice
• Nursing documentation and progress notes that are filled
with misspelled words and poor grammar create a
negative impression.

• Readers may infer that a person with poor spelling and

grammar is uneducated and careless.
Examples of common errors on nursing flow
sheets

• Fecal heart tone heard

• Patient observed to be seeping quietly

• Foley draining fowl smelling urine

Examples of common errors in grammar and
incorrect use of words noted in flow sheets

• Patient has no rigor or chills, but husband states she

was hot in bed last night

• Patient had a cabbage done

• The pelvic exam was done on the floor

• Vaginal packing out, doctor in

• Skin, somewhat pale but present

Avoid in use Inappropriate of grammar

• Some examples

- “IV infiltrated because nightshift forgot to check it”

- “Patient going into shock, could not reach Dr. Jones per usual”

- Physician Note, “Once again the lab forgot to draw the patient’s
PTT this am”

- Physician Note “If the nurses would learn to read medication

orders, we would have a lot fewer emergencies around here”

- “Patient received insufficient care today because nurse patient

ratio was 1:7”

- Physician Note: “Patient fell due to lax nursing supervision”

- “Patient in extreme pain because previous nurse too busy to give

pain meds”
In conclusion:
• Documentation in Nursing Practice is anything
written that describes the status of client on the
care or services given to that client.
• The purpose of documentation in nursing
practice is to facilitate communication, to
promote good nursing care and to meet
professional legal standards.
• Good documentation in nursing should include the
following characteristics i.e. factual, accuracy,
complete, timely (date/time), concise and legible.

Finally remember the importance of using correct

spelling and grammar when documenting, and avoid
inappropriate use of grammar, use of words and
writing inappropriate comments on the nursing flow
sheet.
 30

Do's and Don'ts of Nursing Documentation

Do's
• Check that you have the correct file before you begin writing.
• Make sure your documentation reflects the nursing process.
• 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.
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Do's…..
• 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.

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Don'ts
• Don't chart a symptom, such as "c/o pain," without
also charting what you did about it.
• Don't use shorthand or abbreviations that aren't widely
accepted.
• Don't write imprecise descriptions, such as "a large
amount."
 Students task

Nursing Diagnosis
• Imbalance nutrition : less than body
requirement related to inadequate intake of
nutrition.
• Ineffective airway clearence related to tracheo-
bronchial obstruction
• Anxiety related to change in health status and
situational crisis.
Do the task according to the nursing
diagnose above :
• Make a nursing care plan first and then make a
documentation of implementation according to
the nursing care plan.
• Make at least 3 documentation for each nursing
diagnose
• Do it as handwriting in a paper and then collect
it.
• That’s all.