Documentation in Nursing Practice

DOCUMENTATION IN NURSING PRACTISE

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 (Urquhart et al. 2009).
• 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 in Nursing Practice is anything written or electronically generated that describes the status of client on the care or services given to that client (Perry, A/ G., Potter, P. A. , 2010)
• Nursing documentation refers to written or electronically client information obtained through the nursing process, (Association of Registered Nurses of Newfoundland and Labrador , 2010)
• Document is an integral part of nursing practice and professional of nursing care rather than something that takes away from patient care.
• Document is not optional.

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
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
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
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
• The purpose of documentation in nursing is to facilitate communication, to promote good nursing care and to meet professional legal standards

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 or electronically generated 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. Use N/A or other designation per policy for items that do apply to your patient.
• Do not leave blank N/A

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.
• Draw a line through the blank space so that no additional information can be added.

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 (lawyers and jurors) 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

• MD order, may shower with nurse
• 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

Inappropriate use of grammar, use of words and writing inappropriate comments on the nursing flow sheet such as finger pointing, accusations are surely a red flag to lawyers and jurors.
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 or electronically generated 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, whilst inappropriate use of grammar, use of words and writing inappropriate comments on the nursing flow sheet such as finger pointing, accusations are surely a red flag to lawyers and jurors.