DOCUMENTATION

 Is the process of preparing a complete record of client’s

care. 7. Basis for determining eligibility for care and
 It is a vital tool for communication among the health reimbursement
care team members
8. Permanent legal record of the care that was or was not
PURPOSES of given to the client
DOCUMENTATION
1. Provide database that 9. Component of client classification system
becomes the foundation of care of the client
10. Access to significant epidemiologic data for future
2. Establish communication - with multidisciplinary investigations and research and educational endeavors
team members
11. Compliance with legal, accreditation, reimbursement,
3. Provide Chronologic source of assessment and professional standard requirements
findings - that outline the client’s source of data. ITEMS THAT
NURSES MUST  Assessment
4. Basis for screening or validating proposed DOCUMENT  Nursing diagnosis and
diagnosis patient needs
 Interventions/care provided
5. Source of information - to help diagnostic problems  Patient’s response to care
 Patient’s ability to manage continuing care after
6. Basis for determining educational needs of the discharge
client, family members and significant others

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 9. Record complete information and details for all client
WHO HAS ACCESS symptoms or experiences
TO CHARTS?  Who owns the chart? 10. Include additional assessment content when applicable
 The FACILITY. 11. Support objective data with specific observations
obtained during physical examination
 Patient’s rights
 Agency policy
 The patient have the right to the info in their charts
 They do not have the right to see the chart on
demand or remove anything from the chart, or remove the ASSESSMENT
chart from the facility. FORMS used for
DOCUMENTATION Three types of assessment
GUIDELINES for forms:
1. Initial assessment form
DOCUMENTATION 2. Frequent or ongoing assessment forms
1. Document legibly and print
neatly in non-erasable ink 3. Focused or specialized assessment forms
2. Use correct grammar and spelling
3. Avoid wordiness that creates redundancy 1. INITIAL ASSESSMENT FORM
4. Use phrases instead of sentences to record data
5. Record data findings, NOT how they were obtained  Is called a nursing admission or admission database
6. Write entries objectively without making premature  In this form, you can see details of the patient taken
judgments or diagnoses. during the interview
7. Record the client’s understanding and perception of  This is the form used upon patient submission
problems  The purpose of accomplishing this form is to
8. Avoid recording the word “normal” for normal findings establish a complete database of the patient for problem

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identification, reference and future comparison ASSESSMENT FORM

2. FREQUENT OR ONGOING ASSESSMENT  Forms that are focused on one major area of the
FORMS body for client who have a particular problem
 The purpose of documenting a particular problem in
 Can be found in the chart this form is to determine the status of specific problem
 This forms are accomplished for an ongoing process identified in earlier assessment
of assessment, diagnosing, planning, implementing and  Ex: Cardiovascular or Neurologic
evaluating care Assessment Documentation Forms/Neuro Vital Sign
 Flow charts help staff to record and retrieve data for Form (NVS form)
frequent reassessments  NVS FORM - neurological observations collect
 Ex: vital signs sheets, assessment flow chart/ data on the patient’s neurological status and conveys for
progress notes many reasons including diagnosis, as a baseline observation
 Ex: (1) TPR graphic sheet of NDH. This is following a neurological procedure and following trauma
where the nurse documents the vital signs of the patient therefore it is important all health care professionals are
such as the temperature, calls and respiration efficient and accurate in testing the neurological
(2) Nurses notes - medical note into a medical or status of their patients
health record made by a nurse that can provide an  DOCTOR’S ORDER FORM - this is where
accurate reflection of nursing assessments, changes in the physician’s rights or prescriptions or authorization for
patient’s condition, care provided and relevant the diagnostic or treatment service to a patient
information to support the clinical team to deliver
excellent care OTHER FORMS:
3. FOCUSED OR SPECIALTY AREA (1) KARDEX - widely used concise method of

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organizing and recording data about the client. It consist of (7) DO NOT RESUSCITATE FORM - this is given
a series of cards kept on a portable index file or a computer to patient’s family in the event of cardiac or respiratory
generated forms it maybe a temporary sheet written in arrest or resuscitation is to be done or not
recording frequent changes in the client’s care. (8) CONSENT FOR REFUSAL TO UNDERGO
(2) X-RAY/ULTRASOUND & LABORATORY ANY PROCEDURE - to be filled up by the patient or
REQUEST FORMS - this are the forms for diagnostic any of the family member.
tests. It is printed out of the nurse during the transcription of
the doctor’s order
DOCUMENTATION
(3) CBG MONITORING SHEET - it is where the
nurse documents the sugar level of the patient especially in NOTRE DAME
those with diabetes. People with diabetes require regular HOSPITAL
monitoring of their blood glucose to help them achieve as
close to normal blood glucose level as possible.  In the clinical setting, student nurses are supervised by
their clinical instructor. Their clinical instructor
(4) PARENTERAL FLUID SHEET - on inclusions
assigned them with patients where they can apply the
such as intravenous fluids, side drips, blood transfusions are learned concepts using their critical thinking skills
documented in this form
(5) MEDICATION SHEET- this is where all the
ordered medication for the patients are being recorded. In Carrying-out of
NDH, all stat and prn medications or those medications Doctor’s Order in
given only one needed are written on the last box of the  When a patient is admitted
NDH into the hospital under a
bottom part of the form
particular service, the
(6) DISCHARGE INSTRUCTION SLIP - this is
resident on duty for their service is responsible for
where the instructions of the doctor are written when he/she examining the patient and writing admission orders
at home for the continuity of care  The purpose of the physician’s orders is to communicate

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 the medical care that the patient is to receive while in  Then the nurse will hand over the chart to the clinical
the hospital as well as document the tests, medications, instructor and endorses the order. The clinical instructor
treatments that were ordered. will then check the order and may verify from the nurse
 The COMPONENTS of doctor’s order are:  Then the clinical instructor will then call the assigned
student nurse to carry out the doctor’s order.
1. the DATE that the order was written  The clinical instructor will read the doctor’s order in
2. the ORDER front of the student nurse and give instructions. If the
student nurse will have no clarification, he/she will be
3. the PHYSICIAN’S SIGNATURE asked by the clinical instructor to carry out the order.
4. the TIME that the order was written The student nurse will be closely supervised by the
clinical instructor throughout the process
 After writing the order, the doctor will endorse the chart  In carrying-out the doctor’s order, the student nurse
to the nurse and give further instruction must prepare the following:
 The nurse will then check the order to ensure that all
orders will be transcribed correctly. The nurse can
1. the KARDEX where the student nurse writes all
verify the orders from the doctor who made the order.
significant orders of the doctor such as medication,
 The nurse will also make sure that the 5 RIGHTS are
diagnostic tests, infusions, and procedures to be done. This
included in the doctor’s order: is an up to date record of the care of the patient is receiving.
2. The FORMS for DIAGNOSTIC TESTS,
1. Right name of the drugs PRESCRIPTIONS, and OTHER REQUEST
2. Right name of the patient
3. Right dosage
FORMS if applicable.
4. Right time and frequency 3. MEDICATION TICKET - colored cards for
5. Right route by which the drug is to be administered medication. The color medication ticket depends on the
timing and frequency of drug administration.

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PINK MEDICATION TICKET used for medicines NURSES’ NOTES
which is administered to be used 3 times a day.
The MEDICATION TICKET must contain the
name of the patient, room number, name of the drug, route DOCUMENTATION DO’S and DONT’S
of administration, and frequency.
 DO write DATE and TIME on all entries
 Take note that you are not allowed to revise or rephrase  DO use flowsheet/checklist/kardex. Keep information
the doctor’s order. Write completely what is written in
on flowsheet/checklist current.
the order.
 After writing the order, you must fix your signature and  DO chart as you make observations.
countersign by your clinical instructor  DO write your own observations and sign your own
 All ordered medications will also be written in the name. Sign and initial every entry.
medication sheet  DO describe patient’s behavior and use direct patient
 After transcribing the orders, the student nurse affix quotes when appropriate.
his/her signature after placing a bar sign beside the  DO record exactly what happens to patient and care
doctor’s name. The clinical instructor will then check given.
the transcribed orders.  DO be factual and complete
 If everything is okay, the clinical instructor will  DO use only approved abbreviations.
countersign and endorses back the chart to the nurse.
 DO draw a single line through an error. Mark this entry
as “error and sign your name”
 DO use next available line to chart.
 DO document patient’s current status and response to
medical care and treatments.
 DO write legibly.

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 DO use ink
 DO use accepted chart forms SOAPIE
DOCUMENTATIO
 DON’T begin charting until you check the name and  Subj ective
 Obj N ective
identifying number on the patient’s chart on each page.
 DON’T chart procedures or cares in advance  Ass essment
 DON’T clutter notes with repetitive or frequently  Planning
changing data already charted on the flow  Intervention
sheet/checklist  Evaluation
 DON’T make or sign an entry for someone else
 DON’T change any entry because someone tells you SUBJECTIVE DATA
 DON’T label a patient or show bias
 Is a problem-oriented technique whereby the nurse
 DON’T try to cover up a mistake or incident by identifies and lists the patient’s health concerns
inaccuracy or omission  It is commonly used in primary health-care settings
 DON’T “white out” or erase an error
 DON’T throw away notes with an error on them  Chief complaint or other information the patient or
 DON’T use meaningless words and phrases, such as family member tell you
“good day” or “no complaints”  It is what the patient says about what they are
 DON’T squeeze in a missed entry or “leave space” for experiencing or feeling
someone else who forgot to chart  It includes the patient’s complaints or concerns in the
 DON’T write in the margin patient own words
 EX:
 “feeling achy all over my body…”

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  “...sore throat and chills started last night..” that need to be addressed
 In this section you want to describe the onset, location,
frequency, intensity, duration, or what it makes
better or worse PLANNING
OBJECTIVE DATA  Strategy for
relieving the patient’s problems, including short and
 Factual, measurable data, such as observable signs and long-term actions.
symptoms, vital signs, or test values  This is a deliberative systematic phase of the nursing
 This is what the nurse observes or measures from the process which involves decision making, and problem
patient solving
 EX:  This begins when the first client contact of the patient is
 BP discharged
 Pulse  A plan should be SMART that means that the desired
 Weight outcome is Specific, Measurable, Attainable, Realistic,
 Temperature and Time bounded.
 Findings
 Diagnostic test results

INTERVENTIONS
ASSESSMENT
 Conclusions based on
subjective data and objective data and formulated as  Measures you’ve taken, to achieve expected outcomes
patient problems or nursing diagnoses  This are DIRECT CARE TREATMENT that the nurse
 This is where the nurse identifies problems or issues performs on behalf of client

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 It includes NURSE-INITIATED TREATMENTS  Conclusions drawn on the evaluation determine whether
resulting to nursing diagnosis nursing activities should be terminated, continued, or
 PHYSICIAN-INITIATED TREATMENTS resulting changed
from medical diagnosis  The evaluation continuous until the client achieves the
 This interventions are specifically chosen to move the health goals and or discharge from nursing care
patient towards the desire outcomes or goals
 This interventions need to be based on the patient’s
specific needs and abilities

GUIDELINES for INTERVENTIONS:

 Care NOT documented is NOT done.

 Record nursing activities AFTER they are done
 Up-to-date, accurate and available
 Communicated verbally and in writing

EVALUATION

 Analysis of the effectiveness of your interventions

 It is a planned, ongoing purposeful activity in which
client and health care professionals determine the
CLIENT’S PROGRESS towards achievement of goal
or outcomes and EFFECTIVENESS of the NURSING
PLAN

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