Faculty of Nursing- Damietta University

Maternal Health Nursing and Newborn Department

Prepared by
Prof. Dr./Nahed Fikry
Dean of the Faculty of Nursing, Damietta University
Assist. Prof. Dr. Wafaa Mostafa

Faculty of Nursing
Damietta University
2022-2023
 Faculty of Nursing- Damietta University

COURSE SPECIFICATION
Course Title: Technical Report Writing
Course Code : UMC 427
Credit Hours : 2 / week
Course Level : 4th level
1. COURSE DESCRIPTION:

This course will focus on the concepts of documentation in health care. This
involves understanding reasons for learning and performing good documentation; the
nature and importance of systematic documentation processes. Students will also gain
practical experience by applying the knowledge gained to gather systematic data and
prepare technical report writing as well as demonstrating completion of a patient care
report.

2. OVERALL AIM OF COURSE: This course aims to enable the students understand
the nature and importance of systematic documentation processes, to document patient care
effectively and appropriately and to equip them with report writing skills.

3. INTENDED LEARNING OUTCOMES OF COURSE (ILOs)

By the end of this course each student will be able to:

Level ILOs ‫مخرجات التعلم المستهدفة‬

3.a.Knowledge and understanding ‫المعلىمات والمفاهيم‬
a.1. Identify documentation
a.2. Recognize concept of documentation in emergency
department
a.3. Explain the purposes of documentation in health care..
a.4. Discuss the principles of effective documentation.
a.5. Describe various methods of documentation.
a. 6. Describe various types of documentation records.
a.7. Identify Common examples of documentation in clinical nursing
a.8. Discuss Elements of Effective Documentation
a.9. Illustrate Content of Nursing Documentation

2
 Faculty of Nursing- Damietta University

a.10. Discuss Challenges of Documentation

a.11. Explain Advantages of Electronic Documentation
3.b. Intellectual Skills ‫المهارات الذهنية‬
b.1. Explain how to verify verbal orders.
b.2. Distinguish among different types of emergency
department reports
b.3. Compare different types of emergency department
records.
c.4. Differentiate among the different types of charting.
b.5. Analyze patients information that help in writing report.
b.7. Analyzing the legal and ethical issues in patient documentation
b.8. Criticize pitfalls in a written report
3. c. Transferable Skills ‫المهارات المهنية‬
c.1. Collect patient's information needed to write report using different
approaches
c.2. Conduct writing report.
c.3. Demonstrate writing incident report.

c. 4. Examine a written report.

c.5. Demonstrate Completion of a patient care report format

c.6. Employ quality skills in writing the medical record

c.7. Demonstrate Ethical Decision Making in Documentation

3.d. General Skills ‫المهارات العامة‬
d.1. Communicate effectively with health care team, patient and the patient‘s
support network.
d.2. Using electronic record for professional practice.
d.3 Work within team effectively.
d.4. Follow organizational policies, legal and ethical aspects related to
documentation..

3
 Faculty of Nursing- Damietta University

4. COURSE Outlines
COURSE CONTENTS
UNIT 1 : Introduction and Documentation in Nursing

- Definition of documentation
- When to Complete a Patient Care Record (PCR)?
- How to complete the Patient Care Record?
- Common examples of documentation in clinical nursing
- Types of Documentation
- Purposes of Health Care Documentation
- Elements of Effective Documentation
- Content of Nursing Documentation
- Challenges of Documentation
UNIT 2: Types of Emergency Department Reports
- Emergency department handoff
- Incident Report in accident and emergency
- Operative and procedure reports
- Refusal care report
UNIT 3: Methods of documentation
- Narrative charting
- Source-oriented (SO) charting
- Problem-oriented charting
- PIE charting
- Focus charting
- Charting by exception (CBE)
- Computerized documentation.
UNIT 4: Nursing Documentation Principles
- Principle 1. Documentation Characteristics
- Principle 2. Education and Training
- Principle 3. Policies and Procedures
- Principle 4. Protection Systems
- Principle 5. Documentation Entries
- Principle 6. Standardized Terminology
UNIT 5: Electronic Documentation
- Electronic Health Record
- Advantages of Electronic Documentation
- Challenges of Technology
- Telenurisng
UNIT 6: Communication for Continuity and Collaboration

4
 Faculty of Nursing- Damietta University

-
Written Forms of Communication

Nursing care plan.

Nursing Kardex.

Checklists.

Flow sheets.
- Interpersonal Communication
 Change of shift reports
 Client assignments
 Team conferences
 Rounds
 Telephone calls
UNIT 7: Legal and Ethical Issues of documentation
- Legal Terminology
- Ethical Decision Making and Documentation
- The nurse‘s role in the informed consent
UNIT 8: Documenting Basic Nursing Tasks and Procedures & Abbreviations
UNIT9: Application on documentation

5. TEACHING AND LEARNING METHODS

1. Interactive Lectures
2. Groups Work
3. Student Assignment
6. EVALUATION
Evaluation Weight (100)
Semester Work 20
Midterm Exam 30
Final Exam 50
Total 100

7. TIME:

 Mid-Term exam at week 7th

 Final written exam at week 15th

8. REFERENCES:
A. Course Notes
B. Essential Books
 Brenner, Z.R., Dimitroff, L. J., & Nichols, L.W. (2010). Documentation of
nursing care behaviors. International Journal for Human Caring, 14(4):7-13.

5
 Faculty of Nursing- Damietta University

 Brunetti, L., Hicks, R., & Santell, J. (2007). The impact of abbreviations on
patient safety. The Joint Commission Journal on Quality and Patient Safety,
33(9), 576-583.
 College of Registered Nurses of British Columbia (2012). Practice Support
- Nursing Documentation. Retrieved February 14, 2014, from
http://www.crnbc.ca
 Mosby-Elsevier. (2006). Mosby‘s surefire documentation –how, what, and
when nurses need to document (2nd ed.). St. Louis, MO: Author
 Lippincott, Williams & Wilkins. (2006). Charting made incredibly easy (3rd
ed.) Philadelphia, PA: Author
 Toronto, Ontario: York University, Osgoode Law School (2013). Legal
risk management in documentation and charting for nurses.
 Canadian Nurses Protective Society. (2014). The electronic health record by
Jim Anstey. Webinar June 11, 2014 on http://www.cnps.ca
 Kelley, T.F., Brandon, D.H., & Docherty, S.L. (2011). Electronic nursing
documentation as a strategy to improve quality of patient care. Journal of
Nursing Scholarship, 43(2), 154 – 162.
B. Recommended Books
 DeLaune S. and Ladner P., (2010): Fundamentals of Nursing: Standards and
Practice, Fourth Edition : Printed in the United States of America
 Timby B., (2009): Fundamental nursing skills and concepts, (9 Edition). 2009
th

Wolters Kluwer Health | Lippincott Williams & Wilkins.

 Rebar Ch., (2009): Docu Notes: Clinical Pocket Guide to Effective Charting, Davis
Company, China by Imago
C. Web Sites:
 http://www.cnps.ca
 http://www.crnbc.ca
 Journal of Clinical Nursing
 The Journal of Nursing Administration.
 Journal of Nursing Scholarship
Dean of Faculty: Prof.Dr/ Nahed Fikry Hassan Khedr

Course coordinator: Assist Prof. Dr./ Wafaa Mostafa

6
 Faculty of Nursing- Damietta University

COURSE CONTENTS
UNIT 1 : Introduction and Documentation in Nursing

- Definition of documentation
- When to Complete a Patient Care Record (PCR)?
- How to complete the Patient Care Record?
- Common examples of documentation in clinical nursing
- Types of Documentation
- Purposes of Health Care Documentation
- Elements of Effective Documentation
- Content of Nursing Documentation
- Challenges of Documentation
UNIT 2: Types of Emergency Department Reports
- Emergency department handoff
- Incident Report in accident and emergency
- Operative and procedure reports
- Refusal care report
UNIT 3: Methods of documentation
- Narrative charting
- Source-oriented (SO) charting
- Problem-oriented charting
- PIE charting
- Focus charting
- Charting by exception (CBE)
- Computerized documentation.
UNIT 4: Nursing Documentation Principles
- Principle 1. Documentation Characteristics
- Principle 2. Education and Training
- Principle 3. Policies and Procedures
- Principle 4. Protection Systems
- Principle 5. Documentation Entries
- Principle 6. Standardized Terminology
UNIT 5: Electronic Documentation
- Electronic Health Record

7
 Faculty of Nursing- Damietta University

- Advantages of Electronic Documentation

- Challenges of Technology
- Telenurisng
UNIT 6: Communication for Continuity and Collaboration
- Written Forms of Communication
 Nursing care plan.
 Nursing Kardex.
 Checklists.
 Flow sheets.
- Interpersonal Communication
 Change of shift reports
 Client assignments
 Team conferences
 Rounds
 Telephone calls
UNIT 7: Legal and Ethical Issues of documentation
- Legal Terminology
- Ethical Decision Making and Documentation
- The nurse‘s role in the informed consent
UNIT 8: Documenting Basic Nursing Tasks and Procedures &
Abbreviations
UNIT9: Application on documentation

8
Faculty of Nursing- Damietta University

9
 Faculty of Nursing- Damietta University

Introduction

Nursing documentation is a vital component of safe, ethical and effective nursing

practice, regardless of the context of practice or whether the documentation is
paper-based or electronic. This document describes nurses‘ accountability and the
expectations for documentation in all practice settings, regardless of the
documentation method or storage.

A technical report is a formal report designed to convey technical information in a

clear and easily accessible format. It is divided into sections which allow different
readers to access different levels of information. This guide explains the commonly
accepted format for a technical report; explains the purposes of the individual
sections; and gives hints on how to go about drafting and refining a report in order
to produce an accurate, professional document.

Health care professionals require most of their communication among other

members of the patient‘s healthcare team to be online. In nursing, technical writing
is used for documentation, charting, and instructing.

10
 Faculty of Nursing- Damietta University

Documentation in Nursing

Patient documentation is important to establish a story of the patient‘s situation and

provide a record of communication for others. Each facility that employs nurses
has a policy and procedure about health care documentation that includes the
when, what, and how.

Definition of documentation:

Documentation is any written or electronically generated information about a

client that describes the care or service provided to the client.

When to Complete a Patient Care Record (PCR)?

1. A PCR must be filled out on all patient contacts, during clinical and
practicum time.
2. Complete a PCR on all patients with whom you have contact and whom you
assess.
3. A separate PCR must be completed for each patient transported or treated.
e.g., if a baby is delivered at home and no other resources are available,
separate PCRs are required for mom and baby.
4. PCR‘s must also be completed for inter-facility transfers and assessments
must be completed on those patients as well.

How to complete the Patient Care Record?

1. Record at the time of occurrence

2. Record only what you saw, did or heard.
3. Record in chronological order.
4. Record in a concise, factual and clear manner.
5. Record Corrections Clearly. 6. Record Accurately.

11
 Faculty of Nursing- Damietta University

Common examples of documentation in clinical nursing include:

 Patient assessments.
 Vital signs.
 Weight & height.
 Medication administration.
 Intravenous and blood product therapy.
 Nurse‘s notes.
 Physician/provider orders and notes.
 Laboratory values & radiology reports.
 Surgery reports, and therapy notes.

Types of Documentation: There are two types of documentation namely records

and reports:

 Record: is the permanent written communication that documents

information relevant to a client health care management.
 Report: is oral and/or written communication regarding the patient's health
status, needs, treatment, outcomes, and responses.
 Oral reports are given when the information is for immediate use and not
for permanency
 Written reports are used when the information is to be used by several
persons which is more or less of permanent value

Purposes of Health Care Documentation:

1. Professional responsibility and accountability.

2. Communication,
3. Education,

12
 Faculty of Nursing- Damietta University

4. Research, auditing or statistics.

5. Meeting legal and practice standards,
6. Reimbursement.
1. Professional responsibility and accountability: Documentation provides
written evidence of the practitioner‘s accountability to client, institution, and
society.
2. Communication: Reporting and recording are the major communication
techniques used by health care providers to direct client-based decision
making and continuity of care and to validates the care provided to the
client. The medical record serves as a legal document for recording all client
activities assessed and initiated by health care practitioners.
3. Education: Client‘s medical record can be used for the purpose of
education. Nursing students use medical record as a tool to learn about
disease processes, complications, medical and nursing diagnoses, and
interventions. The results of physical examination and laboratory and
diagnostic testing provide valuable information regarding specific diagnoses
and interventions.
4. Research: Researchers rely heavily on clients‘ medical records as a clinical
data source to determine if clients meet the research criteria of a study.
5. Legal and Practice Standards: Client‘s medical record is a legal document,
and in the case of a lawsuit the record serves as the description of exactly
what happened to a client. Informed consent: Means that the client
understands the reason for and the risks of the proposed intervention and
agrees to the treatment. These documents are usually duplicate copies: the
original goes in the medical record, and the copy is given to the client the
informed consent needs to be signed by the client and witnessed.

13
 Faculty of Nursing- Damietta University

6. Reimbursement: Medical record documentation is the mechanism for

review, which evaluates the intensity of services and the severity of illness
on the basis of a comparison of sample medical records from different
facilities against specific screening criteria. Medical record must provide
documentation that supports the appropriateness of care.

Elements of Effective Documentation: Effective documentation requires:

1. Use of a common vocabulary (Proper use of spelling and grammar).

2. Identify the client, and write in ink.
3. Legibility and neatness.
4. Use of only authorized abbreviations and symbols.
5. Factual and time-sequenced organization.
6. Accurately including any errors that occurred.
1. Use of Common Vocabulary: Nursing practice reflects the use of multiple
terms for nursing interventions, preventing cross institutional comparisons of
nursing care. Use of common vocabulary will also improve intra team
communication and lessen the chance of misunderstandings.
2. Identify the client, and write in ink: every page of client record should
have the client name on it. And every document, information should be
charted in ink or print out from computer.
3. Legibility: Whatever is charted must be easily readable, without any chance
of error. If your handwriting is not readable, print. If you make a mistake, do
not erase or obliterate it; draw one line through the erroneous entry and state
the reason for the error, then sign and date the correction.
4. Abbreviations and Symbols: Facilities usually have a list of acceptable
abbreviations and symbols, approved by the Medical Records Committee, to

14
 Faculty of Nursing- Damietta University

be used when documenting information in the client‘s record. Avoid

abbreviations that can be misunderstood .
5. Factual and time-sequenced organization:
a. Start every entry with the date and time.
b. Chart in a chronological order assessment data, observation, intervention,
and evaluation.
c. Comply with the time frame indicated in the facility‘s guidelines for
documentation: for example, the frequency of charting observations
for a client with restraints or the time frame within which the admit
assessment must be completed.
d. Chart in a timely fashion to avoid the omission of data; it is not a good
practice to wait until the end of the shift to chart on all the clients.
e. Chart medications immediately after administration to avoid errors.
f. Sign your name after each entry.
g. When the nurse forgets to document significant data, it is appropriate and
advisable to include these data at a later date.
6. Accuracy: Accuracy and objective data are crucial if the documentation is
to be useful either clinically or for research. Use factual, descriptive terms to
chart exactly what was observed or done; for example use correct spelling
and grammar, and write complete sentences.

Content of Nursing Documentation:

Nurses or those to whom they delegate client care are responsible for documenting:

 Assessment data.
 Client care needs.
 Routine care such as hygiene measures.

15
 Faculty of Nursing- Damietta University

 Safety precautions that have been used.

 Nursing interventions described in the care plan.
 Medical treatments prescribed by the physician.
 Outcomes of treatment and nursing interventions.
 Client activity.
 Medication administration.
 Percentage of food consumed at each meal.
 Visits or consults by physicians or other health professionals.
 Reasons for contacting the physician and the outcome of the communication.
 Transportation to other departments, like the radiography department, for
specialized care or diagnostic tests, and time of return.
 Client teaching and discharge instructions.
 Referrals to other health care agencies.

Challenges of Documentation

What are the challenges to complete clear (facts only), concise (not wordy),
comprehensive (includes all the necessary details) and timely documentation?
Research studies on documentation and care providers report many reasons for
challenges.

1. Time factors –a nurse may spend between fifteen and twenty five percent
of his or her working day documenting. Another study by Blair and Smith
(2012) concluded that nurses working in acute care may spend between
twenty five and fifty percent of their time documenting. Because you work
in an extremely demanding health care environment, care interactions and
professional skills may take priority to documentation. You may find it
extremely difficult to document client care contemporaneously (at the time

16
 Faculty of Nursing- Damietta University

of occurrence or shortly thereafter) when you are multi-tasking. You may

leave your documentation for less busy times, usually at the end of your
shift or work day.
2. Fatigue – Warren and Creech-Tart (2008) discussed that care provider
fatigue contributes to deficiencies in documentation. Since some care
providers work long hours and have demanding client assignments, they
may not have clear thinking processes required for documentation. You
may think about what needs to be documented, but often do not write it
down. This is especially challenging for you to do when a client has
numerous health problems and requires immediate attention. Being too
busy in a health care setting is not an excuse for poor documentation.
3. False beliefs – With technology becoming more common in the health
services industry, many care providers have a false belief that computers
will do their ―thinking‖ required for documentation. Some care providers
may lack writing or keyboarding skills to complete clear, concise and
comprehensive entries. Whether electronic documentation is used or not
every care provider should strive for accurate documentation, not just
―good‖ charting.
4. Employer support – Some care providers have suggested that employing
facilities and agencies take a more active and supportive role in assisting
employees to become more proficient in documentation. Does your
employer have up-to-date and clear policies and procedures? Do you know
your employer policies and procedures on documentation? Does your
employer provide education and training?
5. Societal factors –There are societal factors that create added pressures for
care providers. With increased media and consumer health awareness,
there is an intense demand for safe, quality care with client involvement.

17
 Faculty of Nursing- Damietta University

The public expects care providers to be flawless in delivery of care, even

when there are increased numbers of clients, particularly the frail elderly
who have complex and chronic medical conditions that require intensified
time for care.
6. Costs and budgets – With an increased emphasis on outcomes and cost
containment, documentation has become one of the main mechanisms for
gathering data. Funding for health care services, including client care and
staffing, is corroborated (checked against) with documentation. If
documentation does not accurately express the high care needs of a client,
then funding is withdrawn or diverted to other areas in the health care
system. Although accurate documentation has its many challenges, this
does not mean that they cannot be overcome or minimized. Your College
in its professional role provides documentation support by way of
standards, practice statements, continuing education and practice
consultants.

18
Faculty of Nursing- Damietta University

19
Faculty of Nursing- Damietta University

20
 Faculty of Nursing- Damietta University

Types of Emergency Department Reports

Emergency department reports may be presented in the form of written statements,

and/or oral.

Types of Emergency Department Reports

1. Emergency department handoff

2. Incident Report in accident and emergency
3. Operative and procedure reports
4. Refusal care report

1. Emergency department handoff

The handoff is a process of transferring primary authority and responsibility

for providing clinical care to a patient from one departing caregiver to one
oncoming caregiver.‖ Commonly occur when patient arrive the health care
agency, or when client care is transferred to another health care provider or
at change of the shift.

Purpose:

 Accurate transfer of information about a patient‘s state and care plan

 Maintain continuity of care or to provide enough input to the next
care area to support a good outcome.
 Increasing team cohesion
 Training, socialization, and emotional catharsis

2. Incident Reports in accident and emergency (A & E)

Incident report used to document any unusual occurrence or accident in the

delivery of client care. Generally the incident is classified as to the type of

21
 Faculty of Nursing- Damietta University

incident i.e. drug error, lack of records, missed diagnosis, as well as

allocating contributory factors.

Purpose of incident report

 Lessons can be learnt from the incident.

 Reduces the possibility of reoccurrence
 Enables monitoring of patient safety issues particular to the
department involved and the trust as a whole.

Barriers to reporting incidents

1. Fear of reprisals
2. Loss of reputation
3. Extra work
4. Poor understanding of the process of investigation of an incident.

Incident reporting process

1. The health team member, who becomes aware of the incident, fills in
the incident report form
2. Discusses the reported incident with the person in charge of the
agency
3. The person reporting the incident at the time classifies the incident
according to the categories supplied with the incident report book.
4. Provide the information on those involved and a factual description of
what happened, including any injury and treatment given.
5. The form is then reviewed by one of the members of the accident and
emergency (A&E) clinical risk management committee (senior
clinicians), who makes an initial assessment of the potential impact of

22
 Faculty of Nursing- Damietta University

the incident including the consequence of the incident in terms of

severity and the likelihood of recurrence (ranging from ‗rare‘ to
‗almost certain‘). These two judgments combine to give a risk
evaluation score.
6. Comments on preventive measures taken or planned (such as an
investigation) are also included.
7. Also note any obvious contributory factors at that time.
8. At this stage a copy of the form is sent to the Trust clinical risk
management office.

23
 Faculty of Nursing- Damietta University

3. Operative and Procedure Reports

A. Document any procedures/ interventions

 Time of orders should be included.

 Document time of first interaction with patient note time (i.e. On ECG when
you sign it).
 Vital signs should be clearly identified and updated
 Re-assess times should be documented.
 Document any communication on the patient's behalf (family, consultants,
old charts, repeated calls to expedite testing / lab results, patient handover,
etc.)

B. Document special signs

 Explain abnormal vitals. (BP 180/95)

 Briefly document important information in phone conversation with
consultants.
 Address all inconsistencies ―historic alternant‖

4. Refusal of Care Reporting:

With the growth in malpractice lawsuits, refusal of care is one of the most difficult
elements of patient care documentation. Competent adult patients have the right to
refuse medical care or to consent to treatment. For a person to refuse care, the
decision must be based on the patient‘s knowledge of his or her situation.

informed about o his or her current situation, the right to receive and refuse
medical care, and the consequences of such a refusal of care.

24
 Faculty of Nursing- Damietta University

needs to be conveyed in a language that the person

understands, and this information must be subsequently documented on the
PCR.

Components of a Thorough Patient Refusal Document

 Evidence the patient is able to make a rational, informed decision.

 Documentation of complete assessment. If the patient refused care or did not
allow a complete assessment, document that the patient did not allow for
proper assessment and document whatever assessments were completed.
 Discussion with the patient as to what care/transportation the provider would
like to do.
 Discussion with the patient as to what may happen if he or she does not
allow care or transportation. Typically these consequences should be listed
clearly and should include the possibility of severe illness/injury or death if
care or transportation is refused.
 Discussion with family/friend/bystanders to try to encourage the patient to
allow care.
 Discussion with medical direction according to local protocol.
 Providing the patient with other alternatives: Going to see his or her family
doctor, having a family member drive him or her to the hospital.
 Signatures: Have a family member, police officer, or bystander sign the form
as a witness. If the patient refuses to sign the refusal form, have a family
member, police officer, or bystander sign the form verifying that the patient
refused to sign.

25
Faculty of Nursing- Damietta University

26
 Faculty of Nursing- Damietta University

Methods of documentation

Documentation must reflect the complexity of care, and it must embody accuracy,
completeness, and evidence of professional practice with efficient and cost-
effective systems. The clinical standards (structure, outcome, process, and
evaluation) are used to develop a system that complies with legal, accreditation,
and professional practice requirements of documentation.

Many methods are used for documentation, including:

• Narrative charting
• Source-oriented (SO) charting
• Problem-oriented charting
• PIE charting
• Focus charting
• Charting by exception (CBE)
• Computerized documentation.

Narrative Documentation:

Narrative charting, the traditional method of nursing documentation, is a story

format that describes the client‘s status, interventions and treatments, and the
client‘s response to treatments. Before the advent of flow sheets, this was the only
method for documenting care. Narrative documentation is easy to use in
emergency situations, in which a simple, chronological order is needed. However,
in this type of documentation it is often difficult to avoid being subjective, and
there is normally a lack of analysis and critical decision making on the part of the
nurse.

27
 Faculty of Nursing- Damietta University

Narrative charting is now being replaced by other formats because:

1. The flow of care is disorganized. It is difficult to show a relationship

between data and critical thinking skills.
2. Each nurse writes with a unique style, making continuity of care difficult to
identify.
3. It fails to reflect the nursing process. The focus is on tasks without emphasis
on assessment data or progress toward achievement of outcomes.
4. It is time-consuming. The paragraphs are free-flowing, so it takes more time
to record accurate data and for others to read it.
5. The information is difficult to retrieve. The same problems may not be
addressed from shift to shift, so it is difficult to track the client‘s progress.

In a nursing information system, narrative charting is accomplished using free text

entry or menu selections.

28
 Faculty of Nursing- Damietta University

Source-Oriented Charting:

Source-oriented (SO) charting is described as a narrative recording by each

member (source) of the health care team on separate records. Because each
discipline has a separate record, care is often fragmented and communication
between disciplines becomes time-consuming. SO charting has similar advantages
and disadvantages to narrative charting since nurses use an unstructured approach
to documenting in the progress notes.

Problem-Oriented Charting:

The focus of (POMR) problem-oriented medical record (POMR) documentation is

on the client‘s problem, with a structured, logical format to narrative charting
called SOAP:

 S: subjective data (what the client or family states)

 O: objective data (what is observed/inspected)
 A: assessment (conclusion reached on the basis of data formulated as client
problems or nursing diagnoses)
 P: plan (actions to be taken to relieve client‘s problem)

SOAPIE and SOAPIER documentation involves taking the SOAP note and
expanding it via:

 I: intervention (measures to achieve an expected outcome)

 E: evaluation (effectiveness of interventions)
 R: revision (changes from the original plan of care)

As you chart according to these systems, think about which piece of information
corresponds with each letter in the SOAP, SOAPIE, or SOAPIER entry.

29
 Faculty of Nursing- Damietta University

The POMR system was modified by nonmedical caregivers and is referred to as

the problem-oriented record (POR). The system is used by hospitals, nursing
homes, and home care agencies.

There are four critical components of POMR/POR:

• Database: Assessment data, representative of all disciplines (history,

physical, nursing admit assessment, laboratory findings, educational and
discharge needs), which become the basis for a problem list evaluation of the
client‘s condition.
• Problem list: Derived from the database: a listing of the client‘s problems as
identified, with each problem numbered and labeled as acute, chronic,
active, or inactive. Nurses use NANDA terminology in writing client
problems as nursing diagnoses; the list is revised as new problems arise and
others are resolved.
• Initial plan: Based on problem identification; the starting point for care plan
development with client participation in setting goals, expected outcomes,
and learning needs.
• Progress notes: Charting based on the SOAP, SOAPIE, or SOAPIER format.

30
Faculty of Nursing- Damietta University

31
 Faculty of Nursing- Damietta University

DART Charting: DART charting includes a record of the following:

 Data observed and reported: This section will include both subjective and
objective data collected.
 Action taken: What did the nurse do to address the concern noted in the
―Data‖ section? This could include pharmacological treatment given per
orders, nursing interventions, comfort measures instituted, and other actions
taken by the nurse.
 Response of the client: How did the client respond to the action that the
nurse took? Did the concern noted in the ―Data‖ section improve or did the
concern magnify?
 Teaching given: What did the nurse tell the client about the concern? This
can include formal teaching, such as discharge instructions, or informal
teachings, such as how to use a call light.

PIE Charting:

After SOAP charting gained in popularity, the problem, intervention, evaluation

(PIE) system was instituted. Whereas SOAP was developed on a medical model,
PIE charting has a nursing origin. PIE is an acronym for problem, intervention, and
evaluation of nursing care.

The key components of this system are assessment flow sheets and nurses‘
progress notes with an integrated plan of care that eliminates the need for a
separate care plan. Each client problem is labeled and numbered for easy reference.
When interventions are implemented to manage the client‘s problem, the problem
number is identified. This system eliminates the traditional care plan by
incorporating an ongoing plan of care into the daily documentation.

32
 Faculty of Nursing- Damietta University

Focus Charting:

Focus charting is a method of identifying and organizing the narrative

documentation of client concerns to include data, action, and response. This
method is not limited to client ‗‗problems‘‘ but allows for the identification of all
‗‗concerns‘‘ such as a significant event (e.g., results of a diagnostic test). when the
results from a SOAP audit revealed weaknesses in writing care plans and charting

33
 Faculty of Nursing- Damietta University

the client‘s response to care. Focus charting uses a columnar format within the
progress notes to distinguish the entry from other recordings in the narrative notes.

34
 Faculty of Nursing- Damietta University

Charting By Exception

Charting by exception (CBE) is a charting method that requires the nurse to

document only deviations from pre-established norms. CBE was instituted to
overcome the recurring problem of lengthy, repetitive notes and to enable the
identification of trends in client status. The CBE system has three key components:

1. Flow sheets: Highlight significant findings and define assessment

parameters and findings.
2. Reference documentation: Is related to the standards of nursing practice. (All
standards are met unless otherwise documented.)
3. Bedside accessibility: Is related to the documentation forms. CBE requires
the nurse to document significant findings and exceptions to predefined
norms.

Electronic charting. Computerized Documentation:

Computerized clinical records systems allow nurses to use computers to store

client data. These systems allow nurses to record client assessment, medication
administration, client teaching, progress notes, care plan updating, client acuity,
and charges into either a bedside computer terminal or a small, portable handheld
terminal. To document nursing interventions and client responses, the nurse
chooses from standardized lists of terms or enters narrative information into the
computer. Automated documentation should provide all normal standards and
allow the nurse to document any exception by menu selection or free text entry.
Flow sheet charting should provide for routine aspects of care to be documented in
tabular form; a pointing device such as a mouse is used to make menu selections or
text entries. The automated MAR is one form of flow sheet charting.

35
Faculty of Nursing- Damietta University

36
Faculty of Nursing- Damietta University

37
Faculty of Nursing- Damietta University

38
 Faculty of Nursing- Damietta University

Nursing Documentation Principles

Accordingly, the American Nurses Association presents these principles:

 Principle 1. Documentation Characteristics

 Principle 2. Education and Training
 Principle 3. Policies and Procedures
 Principle 4. Protection Systems
 Principle 5. Documentation Entries
 Principle 6. Standardized Terminology

Principle 1. Documentation Characteristics: High quality documentation is:

1. Accessible
2. Accurate, relevant, and consistent
3. Auditable
4. Clear, concise, and complete
5. Legible/readable (particularly in terms of the resolution and related qualities
of EHR content as it is displayed on the screens of various devices)
6. Thoughtful
7. Timely, contemporaneous, and sequential
8. Reflective of the nursing process
9. Retrievable on a permanent basis in a nursing-specific manner

Principle 2. Education and Training

Nurses, in all settings and at all levels of service, must be provided comprehensive
education and training in the technical elements of documentation and the
organization‘s policies and procedures that are related to documentation. This
education and training should include staffing issues that take into account the time

39
 Faculty of Nursing- Damietta University

needed for documentation work to ensure that each nurse is capable of the
following:

o Functional and skillful use of the global documentation system

o Competence in the use of the computer and its supporting hardware
o Proficiency in the use of the software systems in which documentation
or other relevant patient, nursing and health care reports, documents,
and data are capture.

Principle 3. Policies and Procedures

The nurse must be familiar with all organizational policies and procedures related
to documentation and apply these as part of nursing practice. Of particular
importance are those policies or procedures on maintaining efficiency in the use of
the ―downtime‖ system for documentation when the available electronic systems
do not function.

Principle 4. Protection Systems

Protection systems must be designed and built into documentation systems, paper-
based or electronic, in order to provide the following as prescribed by industry
standards, governmental mandates, accrediting agencies, and organizational
policies and procedures:

o Security of data
o Protection of patient identification,
o Confidentiality of patient information
o Confidentiality of clinical professionals‘ information
o Confidentiality of organizational information.

40
 Faculty of Nursing- Damietta University

Principle 5. Documentation Entries

Entries into organization documents or the health record (including but not limited
to provider orders) must be:

o Accurate, valid, and complete;

o Authenticated; that is, the information is truthful, the author is
identified, and nothing has been added or inserted;
o Dated and time-stamped by the persons who created the entry;
o Legible/readable; and
o Made using standardized terminology, including acronyms and
symbols.

Principle 6. Standardized Terminologies

Because standardized terminologies permit data to be aggregated and analyzed,

these terminologies should include the terms that are used to describe the planning,
delivery, and evaluation of the nursing care of the patient or client in diverse
setting.

41
Faculty of Nursing- Damietta University

42
 Faculty of Nursing- Damietta University

Electronic Documentation

Technology is rapidly becoming the model for information services in health care.
Informatics is the merging of medical and nursing science with computer science
to better manage health related data and continues to expand in all health care
settings (Mosby, 2006).

Technology systems vary greatly among health care organizations and research has
shown mixed results when comparing paper-based systems to electronic systems
(Kutney-Lee & Kelly, 2011). Computerized documentation systems consist of
complex, interconnected sets of software applications that process and transport
data to and from the health care team. This data guides the health care team in
providing safe, client-centered care while at the same time identifying client needs.

Some systems gather not only data while the client is in care, but retrieve past
client records from various agencies or facilities.

As the general population becomes more computer literate and with increased
government support, a computerized or electronic system is fast becoming the
standard for client records. It is called the electronic health record (EHR). The
client‘s electronic health record contains the same components that a traditional
paper-based health record would have: medical history, clinical status, laboratory
and diagnostic test results, treatments and documentation of client care
interactions. Regardless of whether paper-based or electronic documentation is
used, the same principles of accurate documentation apply.

Computer literacy: refers to a familiarity with the use of personal computers,

including the use of software tools such as word processing, spreadsheets,
databases, presentation graphics, and e-mail.

43
 Faculty of Nursing- Damietta University

Information literacy: is the ability to recognize when information is needed as

well as the skills to find, evaluate, and use needed information effectively.

Information technology (IT): refers to the management and processing of

information with the assistance of computers.

The competencies for the beginning nurse focus primarily on the ability to retrieve
and enter data in an electronic format that supports client care, analyze and
interpret information in planning care, use informatics applications designed for
nursing practice, and implement polices relevant to information.

The ANA (2007) has identified the following informatics competencies for the
beginning nurse:

 The ability to demonstrate basic computer literacy, inclusive of basic

desktop applications and electronic communications.
 The ability to use IT to support clinical and administrative processes such as
information literacy to support EBP
 The ability to access data and perform documentation with computerized
records
 The ability to support safety initiatives through the use of IT
 The ability to define the role of informatics in nursing

The Electronic Health Record

When using electronic health records, the care provider must log on to either enter
or retrieve client information. After entering a password, updated information such
as lab tests or new physician‘s orders may be obtained. Electronic systems
automatically record the care provider‘s name, along with the entry date and time.

44
 Faculty of Nursing- Damietta University

The care provider may use drop down menus to enter assessment data or
significant client notes.

Advantages of Electronic Documentation

1. Electronic documentation has many advantages. It usually speeds up the

time required to document and improves accuracy and legibility, although
this is debateable if the care provider does not know how to use the
electronic system correctly. Therefore, errors may easily occur.
2. Electronic systems reduce reliance on a care provider‘s memory as client
information can often be completed in real time (at the bedside or at the
point of care immediately after care is completed).
3. Sometimes electronic documentation is done at a specific computer station
or at a central location right after the care has been completed.
4. Electronic documentation systems have the ability to reduce redundant
information and prevent recopying of the same client data.
5. Computerized systems permit health care providers who have assignments in
caring for a specific client to enter updated client data so, if required, other
health care team members are immediately informed of changes.
6. Many computerized systems assist in the standardization of care by
providing specific pathways and formats for entering client information.
Most systems incorporate the nursing process. These systems may be
interactive and prompt you with questions about assessment data and follow-
up of the information that you entered. Some interactive systems require you
to enter a brief narrative, while others demand a full narrative on client notes
(CNPS, 2014).
7. There may be mandatory reporting fields for assessment data which ensure
that the care provider does not omit these. Some programs contain

45
 Faculty of Nursing- Damietta University

algorithms that guide a care provider through the nursing process to

document client centered care.
8. Some programs allow a care provider to update prescriptions or these may
be done automatically when the physician changes a prescription.
9. There are software programs that have a discharge plan for health care
services. Others have teaching components that assist care providers with
clients who are in care or are being discharged from care. Some facilities
have voice activated documentation systems. These are more commonly
found in operating rooms and other areas that require high volumes of
structured reports.

The benefits of the HER for nursing:

1. It facilitates comparison of data from different health care encounters.

2. Maintains an ongoing record of a client‘s education and learning in all
encounters.
3. Eliminates the need for repetitive demographic data.
4. Ensures administration and documentation of medications and treatments.
5. Facilitates research, automates critical and clinical pathways.
6. Allows recognition of nursing work in measurable units when used with a
common unified structure for nursing language.

46
Faculty of Nursing- Damietta University

47
 Faculty of Nursing- Damietta University

Challenges of Technology : Technology also has its challenges.

1. Electronic or computer based systems are expensive to design, implement

and maintain. Employing facilities or agencies have large departments
dedicated to the maintenance of electronic records.
2. Electronic systems demand increased staff training which can add
tremendously to costs. In some systems, the care provider must have
keyboarding skills and has to enter progress notes using a narrative format.
3. A health care provider who relies solely on electronic documentation may
interact
4. less with colleagues and reduce collaboration with other health care
providers who may have verbal input to ensure quality client care.
5. Electronic systems may malfunction and routine maintenance may prevent
the access of timely client information. If electronic systems malfunction,
there must be a back-up system to record significant client information –
usually it is of the hand written type.
6. As with any type of electronic technology, there are hackers (individuals
who gain unauthorized access to computer databases) who may violate client
confidentiality or who can actually disrupt huge systems and destroy or
change essential client information.
7. Electronic health systems are constantly being upgraded. Since there are new
and improved technological innovations every year, it is a challenge for
health care providers to keep up.
8. Recent advances in electronic documentation include computerized systems
that enable physicians to prescribe medications electronically. This system
then produces an entry in the medication administration record (MAR). It
has a built-in system that detects incorrect doses or medication interactions

48
 Faculty of Nursing- Damietta University

or abnormal laboratory results. Some medication systems have bar code

technology where the client‘s bar code, the care provider‘s bar code and
medication bar code all have to match. An alarm may be activated if a
medication error is about to occur.

Applications of Nursing Informatics:

‗‗Nursing is a function of healthcare, the following examples of how informatics

and computers support various areas of nursing and consumer health.

Nursing education:

• Online course registration and scheduling and completion of

mandatory education requirements
• Course delivery and support for Web-based education
• Computerized student tracking, testing, grade management, and
communications with students
• Access to remote library and Internet resources
• Capability for podcasts, Webcasts, teleconferencing, and presentation
of prepared slides and handouts

Nurse educators are challenged to transform curricula and teaching methods to

integrate information resources into the cognitive, psychomotor, and
organizational processes of professional practice.

Nursing practice:

• Staff reminders of planned nursing interventions and documentation

prompts to ensure comprehensive charting

49
 Faculty of Nursing- Damietta University

• Computer-generated nursing care plans, critical pathways, and client

documentation such as discharge instructions and medication
information
• Monitoring devices for vital signs and other measurements directly
into the client‘s record
• Automatic billing for supplies or procedures with documentation.
• Access to computer-archived client data from previous encounters
• Online drug information

Nursing research:

• Computerized literature searching.

• Standardized language related to nursing terms.
• Internet access for obtaining data collection tools and conducting
research
• Collaboration with other researchers

IT applications regarding consumer health may include communications with

health care providers through e-mail and instant messaging, online scheduling
of tests or procedures, support groups, and remote monitoring and other
teleheath services. Information access has fostered consumerism that will make
all of health care more accountable (Simpson, 2008).

Telehealth:

Telehealth is seen as a venue for improving health care access in vulnerable

populations through the use of electronic devices in the clients‘ homes that
monitor and assess for early complications (Prinz, Cramer, & Englund, 2008).

50
 Faculty of Nursing- Damietta University

Telehealth refers to the use of telecommunication technologies and computers to

exchange health care information and to provide services to clients at another
location such as health promotion, disease prevention, diagnosis, consultation,
education, and therapy.

Telehealth nursing refers to the utilization of the nursing process via

telecommunications devices with individual clients or defined client
populations (Prinz et al., 2008).

Telehealth devices allow the nurse to monitor pulse oximetry, heart rate, blood
pressure, and weight. Some of the tools used to support these services are voice
only (regular telephone), video images (digital pictures), data exchange
(keyboard and mouse operations), and virtual contact (videoconferencing).

51
 Faculty of Nursing- Damietta University

Telenurisng

Telenurisng giving telephone advice is not a new role for nurses. What is new is
the growing number of people accessing telephone ―help lines‖ to assist their
decision-making about how and when to use health care services. Agencies such as
health units, hospitals and clinics increasingly use telephone advice as an efficient,
responsive and costeffective way to support self-care or to provide health services.
Telenursing is subject to the same principles of client confidentiality as all other
types of nursing care.

Nurses that provide telephone care are required to document the telephone
interaction. Documentation may occur in a written form (e.g., log book or client
record form) or via computer.

Minimum documentation includes the following:

• Date and time of the incoming call (including voice mail messages).
• Name, telephone number and age of the caller, if relevant (when
anonymity is important, this information may be excluded).
• Reason for the call, assessment findings, signs and symptoms
described, specific protocol or decision tree used to manage the call
(where applicable), advice or information given, any referrals made,
agreement on next steps for the client and the required follow-up.

52
Faculty of Nursing- Damietta University

53
Faculty of Nursing- Damietta University

54
 Faculty of Nursing- Damietta University

Communication for Continuity and Collaboration

Documentation as Communication:

Communication is a dynamic, continuous, and multidimensional process for

sharing information as determined by standards or policies. Reporting and
recording are the major communication techniques used by health care providers to
direct client-based decision making and continuity of care. The medical record
serves as a legal document for recording all client activities assessed and initiated
by health care practitioners.

Documentation is defined as written (paper and pen or electronic) evidence of:

1. The interactions between and among health professionals, clients, their

families, and health care organizations
2. The administration of tests, procedures, treatments, and client education
3. The results or client response to these diagnostic tests and interventions

Documentation provides written records that reflect client care provided on the
basis of assessment data and the client‘s response to interventions.

Nurses rely on documentation tools, including computerized systems, that support

the implementation of the nursing process. These tools are the charting records and
systems that facilitate a logical sequencing of events. All the tools used by nurses
to record their nursing care should form a system. Systematic documentation is
critical because it presents the care administered by nurses in a logical fashion, as
follows:

1. Assessment data (obtained by interviewing, observing, and inspecting)

identify the client‘s specific alterations and provide the foundation of the
nursing care plan.

55
 Faculty of Nursing- Damietta University

2. The risk factors and the identified alteration in the functional health pattern
direct the formulation of a nursing diagnosis.
3. Identifying the nursing diagnosis promotes the development of the client‘s
short-term goals, long-term goals, and expected outcomes and also triggers
the nursing interventions. These activities occur during the planning and
implementation phases of the nursing process.
4. The plan of care identifies the nursing interventions necessary to resolve the
nursing diagnosis.
5. Implementation is evidenced by actions the nurse performed to assist the
client in achieving the expected outcomes.

The effectiveness of the nursing interventions in achieving the client‘s expected

outcomes becomes the criterion for evaluation that determines the need for
subsequent reassessment and revision of the plan of care. The system becomes a
vehicle for expressing each phase of the nursing process. Nurses rely on systems
that provide thorough, accurate charting reflective of the nurse‘s decision-making
ability and the client‘s plan of care. The nurse‘s critical thinking skills, judgments,
and evaluation must be clearly communicated through proper documentation.

Although the record serves as an ongoing source of information about the client‘s
status, nurses use other methods of communication to promote continuity of care
and collaboration among the health personnel involved in the client‘s care.

These methods of communication to promote continuity of care are:

A. Written Forms of Communication

B. Interpersonal Communication
A. Written Forms of Communication:

Examples of written forms of communication include:

56
 Faculty of Nursing- Damietta University

1. Nursing care plan.

2. Nursing Kardex.
3. Checklists.
4. Flow sheets.

Nursing Care Plans

A nursing care plan is a written list of the client‘s problems, goals, and nursing
orders for client care. It promotes the prevention, reduction, or resolution of health
problems. Nurses revise the plan of care as the client‘s condition changes.

Most nursing care plans are handwritten on a form that the agency develops. Some
agencies use preprinted care plans, computer-generated care plans, standards of
care, or clinical pathways or cite the plan of care within progress notes.

Because the nursing care plan is part of the permanent record and thus is a legal
document, it is compiled and maintained following documentation principles. All
entries and revisions are dated. The written components are clear, concise, and
legible. The information is never obliterated; only approved abbreviations are used.
Each addition or revision to the plan is signed.

57
 Faculty of Nursing- Damietta University

Nursing Process and Documentation:

The nursing process is the foundation from which nursing professionals provide
care and make decisions to improve client outcomes. The five portions of the
nursing process, as defined and described by the American Nurses Association
(2008), should be evident in any nurse‘s documentation. When encapsulating these
portions of the nursing process, the nurse should strive to include the following
elements in documentation. Whatever charting format nurses use, the
documentation must reflect the nursing process. The nursing process is a scientific
approach that systematically organizes nursing activities to provide the highest
quality of care. The five-step nursing process ensures compliance with care
requirements mandated in both acute and long-term care settings.

Nursing Process and Related Documentation Tools

The steps in nursing process and related document tools:

1. Step 1: Assessment —is a method of collecting information about a client. a

summary of data from the patient‘s history, physical examination and
diagnostic test results (initial assessment form, flow sheets, screening tools)
(Assessment must occur continually throughout the patient’s stay.) It includes:

 Subjective information: Subjective information is reported by the client. It is

how the client feels or how he or she perceives his or her condition. It is stated
by the client, and the nursing professional records what the client explains
about his or her symptoms. Examples include:

 ―My chest pain burns.‖(The nurse could record ―client reports burning chest
pain.‖)

58
 Faculty of Nursing- Damietta University

 ―It feels like I‘m going to throw up when I look at food.‖(The nurse could
record ―client states, ‗it feels like I‘m going to throw up when I look at food‘.‖)
 ―This is just like the last time I had strep throat.‖(The nurse could record
―client states his symptoms are just as they were the last time he had strep
throat.‖)

 Objective information: Information that is gathered through observation,

auscultation, palpation, and percussion. Objective information is collected by
the nursing professional. Examples include findings such as:

 Left eye with purulent discharge.

 Lungs clear to auscultation.
 Tenderness noted upon palpation.
 No hepato-splenomegaly upon percussion.
 Heart–regular rate and rhythm.

2. Step 2: Nursing diagnosis — clinical judgments based on assessment data

(nursing plan of care, patient care guidelines, clinical pathway, progress notes,
problem list) Nursing diagnoses are formulated as a ―clinical judgment
about individual, family, or community responses to actual or potential health
problems/life processes. Nursing diagnoses provide the basis for selection of
nursing interventions to achieve outcomes for which the nurse is accountable‖

The following are examples of nursing diagnoses:

■ Altered bowel habits

■ Fluid or gas alteration or impairment

59
 Faculty of Nursing- Damietta University

■ Dysfunctional grieving

■ Risk for spiritual distress

3. Step 3: Planning—care priorities, goals with outcome criteria and target

dates, description of interventions (plan of care, progress notes, flow sheets)
4. Step 4: Intervention — description of interventions as they are
implemented (progress notes, clinical pathway, graphic records) These are
things that the nurse can do to assist the client in meeting the outcomes. They
might include:

 Treatment interventions, such as placing hot or cold packs, changing dressings,

or administering medications per orders.
 Educational interventions, such as teaching the client about treatments or
actions that will help the client to help himself or herself.
 Referral interventions, such as when a referral to another care provider is
needed; this is usually accomplished in response to a medical order, as occurs
when a treating physician orders physical therapy and the nurse assists in
setting up that appointment.

Effective documentation of nursing interventions should start like this:

 Provided extra pillow beneath heels to prevent skin breakdown.

 Administered 500 mg acetaminophen orally, per orders, for headache.
 Encouraged client to drink one can of nutritional supplement at lunch today.
 Educated client about lean protein and where this is found in different foods.

5. Step 5: Evaluation — outcomes assessment of plan (progress notes,

outcome tool) Evaluation is the measurement of whether the nursing
interventions, which took place during implementation, were effective. It

60
 Faculty of Nursing- Damietta University

demonstrates whether the client has met the established outcomes. If the client
has not met the outcomes, the plan of care can be altered to increase the
chances of success. Documenting evaluations basically means returning to
outcome statements and determining if they were met, based on the
implementation of interventions.

Source: Adapted from Complete Guide to Documentation. 2nd ed. Springhouse,

PA: Lippincott Williams & Wilkins; 2008.
Process of Implementation

ASSESSING

DIAGNOSING
EVALUATING

 Reassessing
 Determining
Need For PLANNING
Assistance
 Implementing
 Supervising
 Documenting

Nursing Kardex:

The nursing Kardex is a quick reference for current information about the client
and his or her care. The Kardex forms for all clients are kept in a folder that allows
caregivers to flip from one to another.

The Kardex has the following uses:

• Locate clients by name and room number

61
 Faculty of Nursing- Damietta University

• Identify each client‘s physician and medical diagnosis

• Serve as a reference for a change of shift report
• Serve as a guide for making nursing assignments
• Provide a rapid resource for current medical orders on each client
• Check quickly on a client‘s diet
• Alert nursing personnel to a client‘s scheduled tests or test preparations
• Inform staff of a client‘s current level of activity
• Identify comfort or assistive measures a client may require

The information in the Kardex changes frequently, sometimes several times in one
day. The Kardex form is not a part of the permanent record. Therefore, nurses can
write information in pencil and erase.

62
 Faculty of Nursing- Damietta University

Checklists:

A checklist is a form of documentation in which the nurse indicates with a check

mark or initials the performance of routine care. It is an alternative to writing a
narrative note. Nurses use checklists primarily to avoid documenting types of care
that are regularly repeated such as bathing and mouth care. This charting technique
is especially helpful when the care is similar each day and the client‘s condition
does not differ much for extended periods.

Flow Sheets:

A flow sheet is a form of documentation with sections for recording frequently

repeated assessment data. It enables nurses to evaluate trends because similar
information is located on one form. Some flow sheets provide room for recording
numbers or brief descriptions.

63
Faculty of Nursing- Damietta University

64
 Faculty of Nursing- Damietta University

B. Interpersonal Communication

In addition to using written resources to exchange information, communication

also takes place during personal interactions among health Professionals.

Some examples are as follows:

• Change of shift reports

• Client assignments
• Team conferences
• Rounds
• Telephone calls

Change of Shift Report

A change of shift report is a discussion between a nursing spokesperson

from the shift that is ending and personnel coming on duty. It includes a
summary of each client‘s condition and current status of care. To maximize
the efficiency of change of shift reports, nurses should do the following:

1. Be prompt so that the report can start and end on time.

2. Come prepared with a pen and paper or clipboard.
3. Avoid socializing during reporting sessions.
4. Take notes.
5. Clarify unclear information.
6. Ask questions about pertinent information that may have been
omitted.

A change of shift report usually includes:

 Name of client, age, and room number

65
 Faculty of Nursing- Damietta University

 Name of physician
 Medical diagnosis or surgical procedure and date
 Range in vital signs
 Abnormal assessment data
 Characteristics of pain, medication, amount, time last administered, and
outcome achieved
 Type of diet and percentage consumed at each meal
 Special body position and level of activity, if applicable
 Scheduled diagnostic tests
 Test results, including those performed by the nurse, such as blood glucose
levels
 Changes in medical orders including newly prescribed drugs
 Intake and output totals
 Type and rate of infusing intravenous fluid
 Amount of intravenous fluid that remains
 Settings on electronic equipment such as amount of suction
 Condition of incision and dressing, if applicable
 Color and amount of wound or suction drainage

Client Care Assignments:

Client care assignments are made at the beginning of each shift. Assignments are
posted, discussed with team members, or written on a worksheet. Each assignment
identifies the clients for whom the staff person is responsible and describes their
care. Meals and break times also may be scheduled as well as special tasks such as
checking and restocking supplies.

66
Faculty of Nursing- Damietta University

67
 Faculty of Nursing- Damietta University

Team Conferences:

Conferences commonly are used to exchange information. Topics generally

include client care problems, personnel conflicts, new equipment or treatment
methods, and changes in policies or procedures. Team conferences often include
the nursing staff, staff from other departments involved in client care, physicians,
social workers, personnel from community agencies, and in some cases, clients and
their significant others.

Usually one person organizes and directs the conference. Responsibilities for
certain outcomes that result from the team conference may be delegated to various
staff members who attend the meeting.

Client Rounds:

Rounds (visit to clients on an individual basis or as a group) are used as a means of

learning firsthand about clients. The client is a witness to and often an active
participant in the interaction. Some nurses use walking rounds as a method of
giving a change of shift report. Giving the report in the client‘s presence provides
oncoming staff with an opportunity to survey the client‘s condition and to
determine the status of equipment used in his or her care. It also tends to boost the
client‘s confidence and security in the transition of care.

68
 Faculty of Nursing- Damietta University

Telephone:

Nurses use the telephone to exchange information when it is difficult for people to
get together or when they must communicate information quickly. When using the
telephone, the nurse does the following:

• Answers as promptly as possible

• Speaks in a normal tone of voice
• Identifies himself or herself by name, title, and nursing unit
• Obtains or states the reason for the call
• Discretely identifies the client being discussed to avoid being publicly
overheard
• Spells the client‘s name if there is any chance of confusion
• Converses in a courteous and business-like manner
• Repeats information to ensure it has been heard accurately

When notifying a physician about a change in a client‘s condition, the nurse

documents in the client‘s record the information reported and the instructions
received. If the nurse believes that the physician has not responded in a safe
manner to the information given, he or she notifies the nursing supervisor or the
head of the medical department.

69
Faculty of Nursing- Damietta University

70
Faculty of Nursing- Damietta University

71
 Faculty of Nursing- Damietta University

Ethical Foundations of Nursing

Every day, nurses encounter situations in which they must make decisions based
on the determination of right and wrong. How do they make such decisions?
Which values determine the rightness of an action? The delivery of ethical health
care is becoming an increasingly difficult and confusing issue in contemporary
society.

Nurses are committed to maintaining clients‘ rights related to health care. This
desire to maintain clients‘ rights, however, often conflicts with professional duties
and institutional policies. It is essential to balance these two perspectives so that
the primary objective, delivery of quality care, is achieved. It is also necessary to
realize that there are no absolute right answers. Dealing with the gray areas
(ambiguities) causes discomfort for some nurses. Ethical guidelines are less clear
and more open to interpretation. In other words, ethical decisions may vary
according to each individual and each situation. Because clients and nurses are
humans, no two situations can ever be exactly alike.

Concept of Ethics

Ethics: is the branch of philosophy that examines the differences between right
and wrong. Simply put, ethics is the study of the rightness of conduct. Ethics deals
with one‘s responsibilities (duties and obligations).

Ethics looks at human behavior—what people do under what type of

circumstances. But ethics is not merely a philosophical discussion; ethical persons
put their beliefs into action.

Often the term morals is mistakenly used when ethics is meant.

72
 Faculty of Nursing- Damietta University

Morality: is behavior in accordance with custom or tradition and usually reflects

personal or religious beliefs.

An example of a moral belief is a person‘s desire to maintain his or her right to die.
Ethics is the free, rational, and publicly stated assessment of alternative actions in
relation to theories, principles, and rules. Ethics is rooted in the legal system and
reflects the political values of our society.

An example of an ethical belief is the practice of parents‘ teaching their children

the importance of telling the truth.

Bioethics : The application of general ethical principles to health care is referred to

as bioethics. Ethics affects every area of health care, including direct care of
clients, allocation of finances, and utilization of staff.

Legal and Ethical Issues:

Documenting appropriately, thoroughly, and accurately is a nurse‘s legal and

ethical responsibility. Concerns about care can easily be brought into question if a
nurse‘s documentation does not support or represent the comprehensive picture of
care that was delivered to the client. When nurses are too brief or casual in their
documentation, document subjectively, or omit key portions of care that was
delivered, it leaves them open to legal action for claims of negligence or
malpractice.

Legal Terminology

As the nursing professional documents, it is helpful to have an understanding of

specific legal terminology. This does not mean that these terms are to be included
in the medical record, but rather that the nursing professional is mindful of legal

73
 Faculty of Nursing- Damietta University

considerations and how appropriate documentation serves to represent

comprehensive, individualized, appropriate care that was provided to a client.

Advance Directives

are the expressed wishes of clients, created when they are lucid and able to make
decisions about their own care. Types of advanced directives include:

 Health Care Proxy

 Living Will
 Do Not Resuscitate (DNR)
 Do Not Resuscitate/Comfort Care (DNR-CC)

Assault:

as it pertains to the health-care profession, involves the threat of bringing harm to

another. Physical contact (called ―battery‖) is not necessary to file a complaint of
assault. Assault can also involve making gestures that are considered threatening,
even without actual physical contact.

Battery:

involves physical contact that is intended to injure another person. Accidental

injury is not considered battery, but would fall under the category of ―malpractice‖
or ―negligence.‖

Defamation:

involves communication, which inflicts injury to a person‘s reputation, and causes

an undesired emotion, such as ridicule, shame, or hatred, to be directed at the
object of the communication. Defamation can encompass ―libel‖ and ―slander.‖

74
 Faculty of Nursing- Damietta University

Good Samaritan Law

was a law created to protect those who attempt toassist another in an emergent
situation.

False imprisonment

occurs when a client is intentionally confined toeither his or her room or with
restraints, without legal authority.

Informed consent

is the practice of making the client aware of all treatment options, including the
benefits and risks associated with these choices, as well as the benefits and risks
associated with rejecting the treatment options. The primary care provider must
provide information to the client during the course of obtaining informed consent;
the nursing professional may witness the document indicating that the client has
given informed consent.

Libel

involves defamation in the form of writing. If the nursing professional writes or

records something about a client that is defamatory, it can be considered libel. This
is the reason that objective, clear, concise, and accurate documentation is so
important.

Malpractice

involves doing something that should not have been done, or not doing something
that should have been done, which resulted in injury to the client. As this relates to
nursing, malpractice means failure to provide the standard of care that a
reasonable, prudent nurse would have provided under the same circumstances, or

75
 Faculty of Nursing- Damietta University

performing an action that a reasonable, prudent nurse would not have performed
under the same circumstances.

Negligence

involves not doing something that should have been done. As this relates to
nursing, negligence means failure to provide the standard of care that a reasonable,
prudent nurse would have provided under the same circumstances. Failing to
document appropriately also falls under the category of negligence.

Restraints

are means by which clients are contained. There are physical restraints, such as
chest-vests, soft or leather wrist or ankle restraints, lap belts, and mitten restraints,
and there are chemical restraints such as medications that cause clients to become
more compliant. Restraints can be medically ordered, with the order being carried
out by the nursing professional; however, as a nurse, you must observe the many
legal requirements for monitoring and documentation of the restrained client. If
restraints are used inappropriately, or in the absence of a medical order, the client
could be considered falsely imprisoned.

Seclusion

involves placing a client, against his or her wishes, in a room or location in which
the client cannot leave. If seclusion is used to promote client safety, the same
standards applying to restraints are to be observed. The nursing professional should
also consult facility policy.

Slander: involves defamation in the form of speech. If the nursing professional

says something about a client that is defamatory, it can be considered slander.

76
 Faculty of Nursing- Damietta University

Ethical Principles:

Ethical principles are tenets that direct or govern actions. They are widely accepted
and generally are based on the humane aspects of society. Ethical decisions are
principled; that is, they reflect what is best for the client and society. By applying
ethical principles, nurses become more systematic in solving ethical conflicts.
Ethical principles can be used as guidelines in analyzing dilemmas; they can also
serve as a justification (rationale) for the resolution of ethical problems. Remember
that these principles are not absolute; there can be exceptions to each principle in
any given situation.

As the nursing professional documents, it is helpful to have an under-standing of

specific ethical principles.

1. Autonomy

involves the individual‘s right to choose for himself or herself; this is a type of
respect that is shown for individual liberty. The client has the right to decide if he
or she desires to take part in certain health-care practices, or to refuse them. Nurses
must respect clients‘ right to decide and protect those clients who are unable to
decide for themselves. The ethical principle of autonomy reflects the belief that
every competent person has the right to determine his or her own course of action.
The right to free choice rests on the client‘s competency to decide.

Upholding autonomy means that the nurse accepts the client‘s choices, even when
those choices are not in the client‘s best interests.

Following are examples of clients‘ autonomous behavior that can impair recovery
or treatment:

• Smoking after a diagnosis of emphysema or lung cancer.

77
 Faculty of Nursing- Damietta University

• Refusing to take medication.

• Continuing to drink alcohol when one has cirrhosis.
• Refusing to receive a blood transfusion because of religious beliefs.

Clients have the right to make their own health care decisions. Based on the
principle of autonomy, this act requires that every person admitted to a health care
facility be informed of the right to self-determination.

2. Beneficence

Is the duty to do good to others. As a nursing professional, nurse is ethically bound

to promote good for the clients. Beneficence is the ethical principle that means the
duty to promote good and to prevent harm. There are two elements of beneficence:

o Providing benefit
o Balancing benefits and harms

One undesirable outcome of beneficence is paternalism, an occurrence in which

health care providers decide what is ‗‗best‘‘ for clients and then attempt to coerce
(or ‗‗encourage‘‘) them to act against their own choices. Paternalistic health care
providers treat competent adults as if they are children who need protection.

Paternalism is usually not considered an ethical approach. However, in some

situations paternalism may be advisable.

3. Fidelity

The concept of fidelity, which is the ethical foundation of nurse-client

relationships, means faithfulness and keeping promises. Clients have an ethical
right to expect nurses to act in their best interests. As nurses function in the role of

78
 Faculty of Nursing- Damietta University

client advocate (a person who speaks up for or acts on behalf of the client), they
are upholding the principle of fidelity. Fidelity is demonstrated when nurses:

• Represent the client‘s viewpoint to other members of the health care

team
• Avoid letting their own personal values influence their advocacy for
clients
• Support the client‘s decision even when it conflicts with the nurse‘s
preferences or choices

Fidelity is the basis of the nurse-client relationship, and reinforces the nurse‘s
obligation to act as a client advocate. For example, if the nursing professional tells
the client that he or she will contact the physician about a possible change in
treatment, the nurse is obligated to follow through and contact the physician.

4. Justice

The principle of justice is based on the concept of fairness. The major health-
related issues of justice involve fair treatment of individuals and allocation of
resource distribution. Justice considers action from the point of view of the least
fortunate in society. As a result of equal and similar treatment of people, benefits
and burdens are distributed equally.

The ethical principle of justice requires that all people be treated equally unless
there is a justification for unequal treatment. The material principle of justice is the
rationale for determining when unequal allocation of scarce resources is
appropriate. This concept specifies that resources should be allocated:

• Equally
• According to need

79
 Faculty of Nursing- Damietta University

• According to individual effort

• According to the individual‘s merit (ability)
• According to the individual‘s contribution to society

For example, if the client states that he or she is uncomfortable having the nurse
perform a task, such as the insertion of a nasogastric-tube, the nurse can utilize the
ethical principle of justice to explain the benefits of the procedure versus the risks.
Then, the client must make a choice that the nurse respects.

5. Nonmaleficence

Nonmaleficence is the duty to cause no harm to others. Harm can take many forms:
physiological, psychological, social, or spiritual. Nonmaleficence refers to both
actual harm and the risk of harm. The principle of nonmaleficence helps guide
decisions about treatment approaches; the relevant question is ‗‗Will this treatment
modality cause more harm or more good to the client?‘‘ Determining whether
technology is harmful to the client is not always a clear-cut decision. Factors to
consider include the following:

• The treatment must offer a reasonable prospect of benefit.

• It must not involve excessive expense, pain, or other inconvenience.

Nonmaleficence requires that the nurse act thoughtfully and carefully, weighing
the potential risks and benefits of research or treatment. Sometimes it is easier to
weigh the risk than to measure the benefit. It is possible to violate this principle
without acting maliciously and without ever being aware of the harm.

Some clinical examples of nonmaleficence are:

• Preventing medication errors (including drug interactions)

• Being aware of potential risks of treatment modalities

80
 Faculty of Nursing- Damietta University

• Removing hazards (e.g., obstructions that might cause a fall)

When upholding the principle of nonmaleficence, the nurse practices according to

professional and legal standards.

6. Veracity

Veracity means truthfulness, neither lying nor deceiving others. Deception can take
many forms: intentional lying, nondisclosure of information, or partial disclosure
of information. Veracity often is difficult to achieve. It may not be difficult to tell
the truth, but it is not always easy to decide how much truth to tell.

Ethical Dilemmas:

An ethical dilemma occurs when there is a conflict between two or more ethical
principles. Ethical dilemmas are situations of conflicting requirements for which
there is no right or wrong option. The most beneficial decision depends on the
circumstances. Ethical analysis is not an exact science. When an ethical dilemma
occurs, the nurse must make a choice between two alternatives that are equally
unsatisfactory.

81
 Faculty of Nursing- Damietta University

Ethical Decision Making and Documentation

The key when documenting an ethical situation is to simply report the facts in an
objective manner. The nursing professional does not have to identify the situation
as an ethical one; the objective documentation is evidence enough to demonstrate
what is being recorded. It is important for the nursing professional to remember
that it is not the nurse‘s responsibility to rectify every ethical issue that he or she
confronts; there are ethical committees or panels in many facilities that specialize
in addressing these concerns professionally and fairly.

Framework for Ethical Decision Making

Once an ethical dilemma is identified, the nurse must determine the relevant parts
of the conflict in order to resolve it. When making an ethical decision, the nurse
must consider the following relevant parts:

• Which theories are involved?

• Which principles are involved?
• Who will be affected?
• What will be the consequences of the alternatives (ethical options)?

82
 Faculty of Nursing- Damietta University

Recognize an Ethical Issue

1. Is there something wrong personally, interpersonally, or socially?

Could the conflict, situation, or decision be damaging to people or to
the community?

83
 Faculty of Nursing- Damietta University

2. Does the issue go beyond legal or institutional concerns? What does it

do to people, who have dignity, rights, and hopes for a better life
together?

Get the Facts

3. What are the relevant facts of the case? What facts are known?
4. What individuals and groups have an important stake in the outcome?
Do some have a greater stake because they have a special need or
because we have special obligations to them?
5. What are the options for acting? Have all the relevant persons and
groups been consulted? If you showed your list of options to someone
you respect, what would that person say?

Evaluate Alternative Actions From Various Ethical Perspectives

6. Which option will produce the most good and do the least harm?
Utilitarian Approach: The ethical action is the one that will produce
the greatest balance of benefits over harms.
7. Even if not everyone gets what they want, will everyone‘s rights and
dignity be respected? Rights Approach: The ethical action is the one
that most dutifully respects the rights of all affected.
8. What options are fair to all stakeholders? Fairness or Justice
Approach: The ethical action is the one that treats people equally, or if
unequally, that treats people proportionately and fairly.

Evaluate Alternative Actions From Various Ethical Perspectives

9. Which options would help all participate more fully in the life we
share as a family, community, society? Common Good Approach:

84
 Faculty of Nursing- Damietta University

The ethical action is the one that contributes most to the achievement
of a quality, common life together.
10.Would you want to become the sort of person who acts this way(e.g.,
a person of courage or compassion)?Virtue Approach: The ethical
action is the one that embodies the habits and values of humans at
their best.

Make a Decision and Test It

11.Considering all these perspectives, which of the options is the right or

best thing to do?
12.If you told someone you respect why you chose this option, what
would that person say? If you had to explain your decision on
television, would you be comfortable doing so?

Act, Then Reflect on the Decision Later

13.Implement your decision. How did it turn out for all concerned? If
you had to do it over again, what would you do differently?

85
 Faculty of Nursing- Damietta University

Incident Report

An incident report is a document that is completed when an incident occurs that

has an adverse outcome, such as an injury incurred while hospitalized, such as
from a fall. Instead of being filed in a client‘s chart, an incident report is circulated
to an appropriate committee that reviews the report and attempts to enact positive
change so that similar episodes do not happen again. This type of committee is
often called something like ―Performance Improvement,‖ ―Clinical Quality
Improvement,‖ or ―Quality Assurance and Improvement. ―Most facilities use an
incident report form that is exclusive to their setting. However, information
contained on incident reports of different facilities

will be very similar. You will use the incident report to record information such as:

 Name and room number (bed number) of client.

 Date and time of incident.
 Location of incident.
 Individual(s) involved in incident.
 Situation of incident (how it occurred).
 Adverse effect of incident, such as injuries sustained.
 Individuals notified, including supervisor, treating physician, family
member.
 Care provided as a result of incident.
 Outcome after care was provided.
 Name and signature of person completing the incident report.

It is important for you to document the incident in the client‘s record, but the
incident report itself should not be included. This documentation should provide an
objective overview of the situation, a record of any care given, the individuals

86
 Faculty of Nursing- Damietta University

notified, and reflect the client‘s current disposition. It is also very important that
you not document that you have completed an incident report. The charting should
remain very objective and address only the facts of the situation.

Informed Consent

Informed consent is a ―process of communication between a client and physician

that results in the client‘s authorization or agreement to under-go a specific
medical intervention‖. The physician must discuss the following information in the
process of this

 The client‘s diagnosis, if known.

 The nature and purpose of a proposed treatment or procedure.
 The risks and benefits of a proposed treatment or procedure.
 Alternatives, regardless of their cost or the extent to which the treatment
options are covered by health insurance.
 The risks and benefits of the alternative treatment or procedure.
 The risks and benefits of not receiving or undergoing a treatment or
procedure.

The nurse’s role in the informed consent:

The nurse‘s role in the informed consent process is to witness the signature of the
client or the power of attorney who can make health-care decisions. Although the
burden of disclosure is on the treating physician, the nurse can assist in the
informed consent process in the following ways:

 Ascertain the alertness of the client. If a client is not alert and oriented,
obtaining informed consent at that time is not appropriate.

87
 Faculty of Nursing- Damietta University

 Clarify with the client whether he has any further questions or concerns prior
to signing.
 Explain that the client can change his mind about giving informed consent,
even if he has already signed the forms. If all of the appropriate conditions
for informed consent have been met, the nurse should document the
following:
 Name of physician providing information to the client.
 The client‘s response to the discussion, including level of understanding
voiced.
 Any questions asked and answered.
 That the informed consent form was signed by the client.

The nursing professional is not witnessing whether the client understood the
information (this burden is placed on the physician), but rather that the actual client
is the one who has signed the informed consent form.

88
Faculty of Nursing- Damietta University

89
 Faculty of Nursing- Damietta University

Informed Refusal

Informed consent is a ―process of communication between a client and physician

that results in the client‘s authorization or agreement to undergo a specific medical
intervention‖ (American Medical Association, 2007). It is always possible that the
client will refuse to sign the informed consent form, even after thorough dialogue
with the physician. If all of the appropriate conditions for informed consent have
been met, the nurse should document the following:

 Name of physician providing information to the client.

 The client‘s response to the discussion, including level of understand-ing
voiced.
 Any questions asked and answered.
 That the informed consent form was not signed by the client with notation of
the client‘s verbalization for why he or she has declined to provide informed
consent.

The nursing professional is not witnessing whether the client under-stood the
information (this burden is placed on the physician), but rather that the actual client
is the one who declined to sign the informed consent form.

90
Faculty of Nursing- Damietta University

91
 Faculty of Nursing- Damietta University

Documenting Basic Nursing Tasks and Procedures

In this section the nurse will find trigger phrases to help her/his document
effectively the nursing tasks and procedures that nurses perform. Keep in mind that
every nurse has his or her own method for safely performing these tasks and
procedures, and documentation should reflect exactly what is done in the order it is
accomplished. Also, not every portion of every category is always carried out,
based on the situation. The list of trigger words can simply help you remember
what content should be documented as it applies to your client‘s situation; it is left
to you, as the nursing professional, to represent that content within the context in
which it happened.

Arterial Blood Gas (ABG) Sampling:

 Date and time of procedure.

 Explanation of procedure to client.
 Vital signs prior to procedure.
 Site of arterial puncture.
 Allen‘s test.
 Circulatory assessment.
 Time spent applying pressure to site of sample.
 Assessment of site after procedure is complete.
 Notation of any oxygenation client is receiving.
 Vital signs after procedure.
 Pertinent client teaching given.
 Client response to procedure

Bandaging:

 Date and time of procedure.

92
 Faculty of Nursing- Damietta University

 Explanation of procedure to client.

 Assess skin for any contraindication to wrapping.
 Notation of type of wrap used.
 Notation of method of wrapping, such as figure 8 or spiral wrap.
 Pertinent client teaching given.
 Client response to procedure.

Blood Product Administration:

 Physician order.
 Signed consent form, if not for emergent purposes.
 Transfusion history, if client has received blood before.
 Date and time of procedure.
 Explanation of procedure given to client.
 Client teaching given to client regarding potential side effects that must be
reported to the nurse:
 Itching.
 Dyspnea, shortness of breath.
 Chills or rigors.
 Headache.
 Chest pain.
 Back pain.
 Urticaria, hives.
 Flushing.
 Validation of blood product and client with another registered nurse. (Note:
Make sure to list the name of the nurse.)
 Client‘s name.
 Client‘s medical record number.

93
 Faculty of Nursing- Damietta University

 Client‘s date of birth.

 Blood donor number on bag.
 Blood donor number on blood bank form.
 Client‘s blood type.
 Client‘s Rh type.
 Crossmatch compatibility.
 Donor‘s blood type.
 Donor‘s Rh type.
 Unit and product number.
 Expiration date and time.
 Type of blood component versus what is ordered (for example, areyou going
to hang platelets, and were platelets what was ordered?).
 Vital signs before administration of blood product.
 Catheter type and gauge used.
 Use of normal saline with blood product.
 Warming unit used, if applicable.
 Rate of infusion.
 Vital signs during transfusion, usually every 5 minutes for the first15
minutes, and then every 15 minutes thereafter.
 Total amount transfused.
 Date and time of transfusion completion.
 Any information about client‘s condition or response during andfollowing
transfusion, including intermittent vital signs.
 Documentation of blood bag form to be returned to blood bank.

Blood Specimen Collection:

 Date and time of procedure.

94
 Faculty of Nursing- Damietta University

 Explanation of procedure to client, particularly type of collection.

 Venipuncture.
 Arterial puncture.
 Capillary, such as Glucometer testing.
 Note regarding the method of collection.
 Pertinent client teaching provided.
 Client response to procedure

Delivery of Medication:

Most facilities have a dedicated medical administration record (MAR) of some

kind. The nurse should comply with the institution‘s policies on documenting
medication administration on this form. Key points to remember that are common
to virtually all MARs include:

 The nurse must sign the MAR once he or she has administered the first dose
of medication to the client. The MAR should not be signed prior to giving
any medication in case there are delays, transfers, or refusals that would
preclude the nurse from delivering medication.
 The nurse should indicate that a dose of medication was given only after the
client has received it. The nurse should never chart ahead in case there is a
complication or situation in which the client refuses, or is unable to take, a
dose of medication.
 If a medication is not given based on nursing assessment or client refusal,
the nurse must circle the time of that dose and document in the narrative
record why the medication was not delivered.
 When preparing to deliver medication, the nurse must check the ―Five
Rights.‖ It is important to consider the same ―Five Rights‖ when

95
 Faculty of Nursing- Damietta University

documenting to ensure that all information is accurately charted. These

include:
1. Right client: Double check to make certain you are documenting on the
right client‘s chart and MAR.
2. Right time and frequency: Make certain you are accurately recording the
time you delivered the medication.
3. Right drug: Completely record the name of the medication given, if writing
a narrative note. Do not abbreviate names or amounts; for example, write out
―milligrams‖ instead of ―mg.‖
4. Right dose: Be astute to record the right dose given; watch decimal points
specifically so that there is no question about what was delivered.
5. Right route: Accurately record the route by which medication was
delivered. If given via intramuscular, intradermal, or subcutaneous delivery,
record the exact location where the medication was administered.

It is also important to observe all regulations that apply to narcotics administration

and documentation. These types of regulations encompass federal, state, and
institutional protocols. You are responsible for observing all of these regulations.

Glucose Testing:

 Date and time of procedure.

 Explanation of procedure to client.
 Notation of quality controls done in the past 24 hours.
 Site used for sample.
 Results of glucose testing.
 Pertinent client teaching provided.
 Client‘s response to procedure.

96
 Faculty of Nursing- Damietta University

Intake and Output:

 Date and time of monitoring.

 Explanation of procedure to client.
 Measurement of all forms of intake.
 Urine.
 Intravenous fluid.
 Intravenous medications, such as piggybacks.
 Oral intake.
 Measurement of all forms of output.
 Urine.
 Vomitus.
 Draining, such as nasogastric suction, wound drains.
 Blood loss.
 Pertinent client teaching provided

Intramuscular Injection:

 Date and time of procedure.

 Explanation of procedure to client.
 Notation of injection site.
 Type of medication given with dosage—record also on MAR.
 Pertinent client teaching given.
 Client response to procedure.

Intravenous Medication Administration:

 Date and time of insertion.

 Explanation of procedure to client.
 Notation of site of administration.

97
 Faculty of Nursing- Damietta University

 Compatibility checked against IV fluid, if infusing.

 Type of medication given with dosage—record also on MAR.
 Amount of solution infused, if piggyback.
 Flow rate of current infusion, if piggyback.
 Pertinent client teaching provided.
 Client‘s response to procedure.

IV Therapy:

Sometimes a nurse simply maintains IV therapy without being responsible for

inserting the initial IV line or changing it. To document monitoring of IV therapy,
the following trigger words apply:

 Date and time of procedure.

 Assessment of IV site, including such data as color, presence or absence of
swelling, temperature, tenderness.
 Provision of continued education about procedure.
 Type of solution.
 Amount of solution infused.
 Flow rate of current infusion.
 Pertinent client teaching provided.
 Client response to procedure.

Oxygen Administration:

 Date and time of procedure.

 Explanation of procedure to client.
 Assessment of SpO2, lung sounds, respiratory rate, and respiratory effort.
 Application of oxygen.
 Use of mask or cannula.
 Flow rate.
 Re-assessment of SpO2, lung sounds, respiratory rate, and respiratory effort.
 Pertinent client teaching given.
 Client response to procedure.

Urine Sample Collection:

 Date and time of procedure.

98
 Faculty of Nursing- Damietta University

 Explanation of procedure to client, particularly of type of collection.

 Regular urinary analysis.
 24-hour urine collection.
 Closed drainage collection.
 Clean-catch sample.
 Note regarding the method of collection.
 Pertinent client teaching provided.
 Client response to procedure.

Abbreviations

Terminology used in health care is virtually a language unto itself. Just as attorneys
learn to talk about legal issues, nurses must learn to converse and document about
health-care issues. In order to ensure accurate transfer of information between
people and continuity of care, it is important to understand the language of health-
care providers. A large part of communication in health care is documented by
using abbreviations. However, this is not the ideal method of charting, because the
use of abbreviations can contribute to errors by opening the door to the possibility
of misinterpretation and charting errors. When a nurse makes a conscientious effort
to write out all portions of his or her documentation, this potential for error is
greatly diminished. However, because abbreviations are used within health-care
systems, nurses must be able to interpret them and be astute to any potential for
error.

Commonly Abbreviated Words:

The following is a list of commonly abbreviated words. This is by no means

inclusive of all abbreviations used in practice, but it does represent those most
frequently used.

ADLs . . . . . . . . . . . . . Activities of daily living

A&O . . . . . . . . . . . . . Alert and oriented
AB . . . . . . . . . . . . . . . Antibody
ABG . . . . . . . . . . . . . Arterial blood gas
ARDS . . . . . . . . . . . . Adult respiratory distress syndrome

99
 Faculty of Nursing- Damietta University

ARF . . . . . . . . . . . . . . Acute renal failure

ADH . . . . . . . . . . . . . Antidiuretic hormone
AKA . . . . . . . . . . . . . Above-the-knee amputation
BC . . . . . . . . . . . . . . . Blood cultures
BID . . . . . . . . . . . . . . Twice daily
BM . . . . . . . . . . . . . . Bowel movement
BP . . . . . . . . . . . . . . . Blood pressure
BUN . . . . . . . . . . . . Blood urea nitrogen
Bx . . . . . . . . . . . . . . . Biopsy
CC . . . . . . . . . . . . . . . Chief complaint
c/o . . . . . . . . . . . . . . . Complains of
CP . . . . . . . . . . . . . . . Chest pain
CRF . . . . . . . . . . . . . . Chronic renal failure
CA . . . . . . . . . . . . . . . Cancer/carcinoma
Ca . . . . . . . . . . . . . . . Calcium
CAD . . . . . . . . . . . . . Coronary artery disease
CAH . . . . . . . . . . . . . Chronic active hepatitis
CBC . . . . . . . . . . . . . Complete blood count
CXR . . . . . . . . . . . . . Chest x-ray
D&C . . . . . . . . . . . . . Dilation and curettage
DDx . . . . . . . . . . . . . Differential diagnoses
DI . . . . . . . . . . . . . . . Diabetes insipidus
DM . . . . . . . . . . . . . . Diabetes mellitus
DOB . . . . . . . . . . . . . Date of birth
DVT . . . . . . . . . . . . . Deep vein thrombosis
Dx . . . . . . . . . . . . . . . Diagnosis
ECG (EKG) . . . . . . . Electrocardiogram

100
 Faculty of Nursing- Damietta University

ECHO . . . . . . . . . . . . Echocardiogram
ED . . . . . . . . . . . . . . . Emergency department
EENT . . . . . . . . . . . . Eyes, ears, nose, throat
ENT . . . . . . . . . . . . . Ears, nose, throat
ESLD . . . . . . . . . . . . End-stage liver disease
ET . . . . . . . . . . . . . . . Endotracheal
FB . . . . . . . . . . . . . . . Foreign body
FBS . . . . . . . . . . . . . . Fasting blood sugar
F/C . . . . . . . . . . . . . . Fever/chills
FH . . . . . . . . . . . . . . . Family history
FSH . . . . . . . . . . . . . . Follicle stimulating hormone
FTT . . . . . . . . . . . . . . Failure to thrive
F/U . . . . . . . . . . . . . . Follow-up
Fx . . . . . . . . . . . . . . . Fracture
GYN . . . . . . . . . . . . . Gynecological
HA . . . . . . . . . . . . . . Headache
HAV . . . . . . . . . . . . . Hepatitis A virus
HBV . . . . . . . . . . . . . Hepatitis B virus
HIV . . . . . . . . . . . . . . Human immunodeficiency virus
Hb & Hgb . . . . . . . . . . . Hemoglobin
HTN . . . . . . . . . . . . . Hypertension
H/O . . . . . . . . . . . . . . History of
I&O . . . . . . . . . . . . . . Intake and output
ICU . . . . . . . . . . . . . . Intensive care unit
ID . . . . . . . . . . . . . . . Infectious disease
IDDM . . . . . . . . . . . . Insulin-dependent diabetes mellitus

101
 Faculty of Nursing- Damietta University

Ig . . . . . . . . . . . . . . . Immunoglobulin
IM . . . . . . . . . . . . . . . Intramuscular
IUD . . . . . . . . . . . . . . Intrauterine device
LFT . . . . . . . . . . . . . . Liver function test
LGI . . . . . . . . . . . . . . Lower gastrointestinal
LH . . . . . . . . . . . . . . . Luteinizing hormone
LLQ . . . . . . . . . . . . . Left lower quadrant
LMP . . . . . . . . . . . . . Last menstrual period
MVA . . . . . . . . . . . . . Motor vehicle accident
NG . . . . . . . . . . . . . . Nasogastric
NIDDM . . . . . . . . . . . Non–insulin-dependent diabetes mellitus

OB . . . . . . . . . . . . . . Obstetrics
ONC . . . . . . . . . . . . . Oncology
PCN . . . . . . . . . . . . . Penicillin
PID . . . . . . . . . . . . . . Pelvic inflammatory disease
PMH . . . . . . . . . . . . . Past medical history
PMS . . . . . . . . . . . . . Pre-menstrual syndrome
PRN . . . . . . . . . . . . . As needed, as necessary
PT . . . . . . . . . . . . . . . Client
qd . . . . . . . . . . . . . . . Daily
qh . . . . . . . . . . . . . . . Hourly
qid . . . . . . . . . . . . . . Four times daily

102
Faculty of Nursing- Damietta University

103
 Faculty of Nursing- Damietta University

Application on documentation

Refer to the following case study of Helena Cortez when reviewing the different
types of documentation. Helena Cortez, a 40-year-old Hispanic American, has a
known diagnosis of hypertension. She has been treated in the past with medication.
Over the past few weeks, she has not taken her medication because she cannot
afford it. Today, she developed a throbbing headache while driving her vehicle and
subsequently was involved in a motor vehicle accident when she drove off the
road. She has a fractured right femur, multiple rib fractures, and multiple
abrasions. MS. Cortez speaks some English, but prefers to speak Spanish. There
are a limited number of translators in the hospital. She has no one at home other
than her 2-year-old son, Hector, and her elderly mother, who is caring for Hector
since the accident. Ms. Cortez‘s initial assessment in the emergency department
revealed that she was mildly confused about the date, but she was oriented to per-
son and place. She states that she had no bowel or bladder control issues at the time
of the accident. The emergency physician ordered a complete blood count (Hgb
11.0, Hct 37, WBC 9.0). A computed tomography scan of the head was normal.
She had two small lacerations on her left arm that were sutured. Vital signs were T
98.0, R 20, BP 200/100, P 90.Ms. Cortez has been admitted to your unit for
monitoring and care. She is still complaining of a headache (6 out of 10 on a 1 to
10 scale with 1being no pain and 10 being the most severe pain ever experienced)
and rubs her temples. Her pupils are equal, round, and reactive to light and
accommodation. Vital signs include temperature 98.2, pulse 88, respirations 18,
and blood pressure 180/90. Oxygen saturation is 96% on room air. Her heart has a
regular rate and rhythm, and her respirations are unlabored. Capillary refill is 3
seconds. Lung sounds are clear. She has some mild left upper quadrant tenderness
but she thinks this ―might be where the ribs are broken.‖ Bowel sounds are

104
 Faculty of Nursing- Damietta University

normoactive in all quadrants. Her strength is equal in all extremities, although

there is a positive Homans‘sign on the left. The primary-care provider has stated
that Ms. Cortez will be in thehospital at least 3 days while they attempt to control
her hypertension and monitor her fractures. Now that there is a positive Homans‘
sign, Ms. Cortez is worried that she‘ll be in the hospital even longer. This concerns
her because she is a single parent and is afraid of what will happen to Hector if
she‘s in the hospital for a lengthy amount of time. Her elderly mother is unable to
care for the needs of a toddler for very long, as she is not well either. The orders
left for Ms. Cortez by the primary-care provider, Dr. Smith, include a low-sodium
diet, which Ms. Cortez does not like, because she salts almost everything; TED
hose; BSC; and VS every 2 hours to monitor hypertension. Dr. Smith has written
for Tylenol ES, 650 mg by mouth, q 6 hours for headache. As you enter the room
to apply the TED hose, Ms. Cortez is praying the rosary and crying softly. When
she looks up, she tells you that she needs to smoke a cigarette to calm her nerves.

Narrative documentation:

11 December 2022, 1100: Admitted for monitoring; still notes headache with
severity of 6/10 on 1–10 scale while rubbing temples. T 98.2, R 18, BP180/90, P
88. SpO2 96% on room air. Heart RRR. Capillary refill 3 seconds. Lungs CTA.
Mild LUQ tenderness reported where she ―thinks [her] ribs are broken.‖ Bowel
sounds x 4 quadrants. Strength equal in all extremities. Positive Homans‘ sign
LLE. Concerned about length of stay in hospital and who will care for her son and
elderly mother; noted to be saying the rosary and crying softly. States she needs to
smoke a cigarette to calm her nerves.
__________________________________________________________________
___________________G. Nurse,RN

105
 Faculty of Nursing- Damietta University

Charting By Exception (CBE):

11 December 2022, 1100: Notes headache with severity of 6/10 on 1–10 scale
while rubbing temples. BP 180/90. Mild LUQ tenderness reported where she
―thinks [her] ribs are broken.‖ Positive Homans‘ sign LLE. Concerned about
length of stay in hospital and who will care for her son and elderly mother; noted
to be saying the rosary and crying softly. States she needs to smoke a cigarette to
calm her nerves._________________________________________ G. Nurse, RN

DART Charting:

11 December 2022, 1100

 D: States headache is 6 of 10 on a 1–10 scale; crying softly, rubbing

temples; PERRLA.
 A: Tylenol ES, 650 mg, given per order.
 R: Twenty minutes later, client reports pain is now 3 of 10 on a 1–10
scale.
 T: Reminded client to use call light to report any increase in head pain.
________________________G. Nurse, RN

11 December 2022, 1130

 D: Worried about who will care for elderly mother and son; noted to be
crying softly and praying the rosary.
 A: Call placed to social services department to discuss options for care
for elderly mother and son.
 R: Client stated ―thank you‖ for calling social services.

106
 Faculty of Nursing- Damietta University

 T: Educated client about function of social services, and that they are an
appropriate resource for assisting clients in finding answers to concerns
such as hers. ______________________________________ G. Nurse, RN

11 December 2022, 1215

 D: Stated ―ouch!‖ when dorsiflexing left foot; noted facial grimace when
dorsiflexion left foot.
 A: Apply TED hose per orders; will continue to monitor.
 R: Two hours later, client still with discomfort upon dorsiflexion of
LLE.
 T: Educated client about function of TED hose, and the importance of
continuing to wear them while hospitalized. ____________ G. Nurse, RN

FOCUS Charting:

11 December 2022, 1100

■ Focus: Head pain related to hypertension.

■ Data: States headache is 6 of 10 on a 1–10 scale; crying softly, rubbing

temples; PERRLA.

■ Action: Tylenol ES, 650 mg, given per order.

■ Response: Twenty minutes later, client reports pain is now 3 of 10 on

a 1–10 scale.____________ G. Nurse, RN

 11 December 2022, 1130

 Focus: Anxiety related to family concerns.

107
 Faculty of Nursing- Damietta University

 Data: Worried about who will care for elderly mother and son; noted to
be crying softly and praying the rosary.
 Action: Call placed to social services department to discuss options for
care for elderly mother and son.
 Response: Client stated ―thank you‖ for calling social services._______
__________ G. Nurse, RN

11 December 2022, 1215

 Focus: LLE pain related to dorsiflexion.

 Data: Stated ―ouch!‖ when dorsiflexing left foot; noted facial grimace
when dorsiflexing left foot.
 Action: Apply TED hose per orders; will continue to monitor.
 Response: Fifteen minutes later, client still with discomfort upon
dorsiflexion of LLE. Will continue to monitor.
__________________________G. Nurse, RN

PIE Charting:

11 December 2022, 1100

 P: States headache is 6 of 10 on a 1–10 scale; crying softly, rubbing temples;

PERRLA.
 I: Tylenol ES, 650 mg, given per order.
 E: Twenty minutes later, client reports pain is now 3 of 10 on a 1–10 scale.
Reminded client to use call light to report any increase in head pain.
___________ G. Nurse, RN

11 December 2022, 1130

108
 Faculty of Nursing- Damietta University

 P: Worried about who will care for elderly mother and son; noted to be
crying softly and praying the rosary.
 I: Call placed to social services department to discuss options for care for
elderly mother and son.
 E: Client stated ―thank you‖ for calling social services.
___________________________G. Nurse, RN

SOAP Charting:

11 December 2022, 1100

S: States headache is 6 of 10 on a 1–10 scale.

O: Crying softly, rubbing temples; PERRLA.

A: Head pain r/t hypertension.

P: Tylenol ES, 650 mg, given per order. Twenty minutes later, client

reports pain is now 3 of 10 on a 1–10 scale. ________________________

____________________________________________________ G. Nurse, RN

11 December 2022, 1130

S: Worried about who will care for elderly mother and son.

O: Noted to be crying softly and praying the rosary.

A: Need for social service intervention.

P: Call placed to social services department to discuss options for

care for elderly mother and son. ___________________________________

109
 Faculty of Nursing- Damietta University

____________________________________________________ G. Nurse, RN

11 December 2022, 1215

S: Stated ―ouch!‖ when dorsiflexing left foot.

O: Noted facial grimace when dorsiflexing left foot.

A: Positive Homans‘ sign, LLE.

P: Apply TED hose per orders; will continue to monitor. _____________

____________________________________________________G. Nurse, RN

SOAPIE Charting:

 11 December 2022, 1130

 S: Worried about who will care for elderly mother and son.
 O: Noted to be crying softly and praying the rosary.
 A: Need for social service intervention.
 P: Social services to be called.
 I: Call placed to social services department to discuss options for care
for elderly mother and son.
 E: Client notified that social services will be coming in for a consult;
client states, ―thank you—that helps ease my mind.‖ _______________

_______________________________________________ G. Nurse, RN

11 December 2022, 1215

 S: Stated ―ouch!‖ when dorsiflexing left foot.

 O: Noted facial grimace when dorsiflexing left foot.
 A: Positive Homans’ sign, LLE.

110
 Faculty of Nursing- Damietta University

 P: TED hose ordered by Dr. Smith.

 I: Applied TED hose per orders; will continue to monitor.
 E: Tolerated application of hose without discomfort; states that hose
feel comfortable. __________________________________ G. Nurse, RN

SOAPIER Charting:

11 December 2022, 1130

 S: Worried about who will care for elderly mother and son.
 O: Noted to be crying softly and praying the rosary.
 A: Need for social service intervention.
 P: Social services to be called.
 I: Call placed to social services department to discuss options for care
for elderly mother and son.
 E: Client still crying; states she ―feels as though God is punishing‖ her.
 R: Chaplain services offered; client agreed to talk with chaplain.
Chaplain services contact. __________________________ G. Nurse, RN

11 December 2022, 1215

 S: Stated ―ouch!‖ when dorsiflexing left foot.

 O: Noted facial grimace when dorsiflexing left foot.
 A: Positive Homans’ sign, LLE.
 P: TED hose ordered by Dr. Smith.
 I: Applied TED hose per orders; will continue to monitor.
 E: States TED hose are very tight and uncomfortable.
 R: Remeasured for TED hose; one size larger ordered from Central
Supply. _______________________________________ G. Nurse, RN

111
 Faculty of Nursing- Damietta University

Another Example:

Mr. Ahmed is a 50-year old businessman who was admitted to the hospital with
pneumonia. His vital signs have been stable this morning. Mr. Ahmed says he feels
very ―washed out‖ today. This morning, he ate all of his breakfast and walked to
the bathroom with the help of a nursing assistant. Mr. Ahmed currently has a
headache, which he rates as a 7 on a 1–10 scale. He thinks it started after he read
too much without his glasses. Upon physical examination, the nurse notes nothing
unusual. The nurse has administered Tylenol, 650 mg, which is on his ―prn‖
medication orders. Thirty minutes later, Mr. Ahmed says his headache is better and
is now a 2 on a 1–10 scale. The nurse lets him know to use the call light if the
headache returns or he has any concerns or needs.

Narrative:

11 June 2022, 1109: Vital signs stable (see flow sheet). Physical examination
(assessment) unremarkable. States he feels ―washed out.‖ 100% of breakfast
consumed; ambulated to bathroom with assist. States has headache of 7 on 1–10
scale due to not using glasses when reading. Tylenol, 650 mg, administered as
ordered._____________________________ G. Nurse,RN

11 June 2022, 1140: States headache is now 2 on 1–10 scale. Instructed to use call
light if headache returns or develops other concerns._____________ G. Nurse, RN

SOAP:

11 June 2022, 1215

■ S: Reports headache of 7 on 1–10 scale.

■ O: Physical examination (assessment) unremarkable.

112
 Faculty of Nursing- Damietta University

■ A: Pain (head) is r/t not using glasses when reading.

■ P: Tylenol, 650 mg, administered as ordered ________________________

____________________________________________________ G. Nurse, RN

*Note: The SOAP note does not have a field for recording the client‘s response to
treatment. Therefore, another SOAP note would be needed to follow up.

11 June 2022, 1300

■ S: States headache is now a 2 on 1–10 scale.

■ O: Physical examination (assessment) unremarkable.

■ A: Pain (head) r/t not using glasses when reading resolved.

■ P: Continue to monitor; client to use call light if headache returns ____

_____________________________________________________G. Nurse, RN

DART

11 June 2022, 1215

■ D: Reports headache of 7 on 1–10 scale. Physical examination (assessment)

unremarkable.

■ A: Tylenol, 650 mg, administered as ordered.

■ R: States headache is now a 2 on 1–10 scale.

■ T: Instructed to use call light if headache returns or develops other

concerns. ______________________________________________ G. Nurse, RN

113
 Faculty of Nursing- Damietta University

*Note: The ―D‖ in the DART includes both subjective and objective
information collected by the nurse. Because components of the DART note
may occur at varying times, the nurse can select only the components
exercised at one time. For example, the previous note would likely read like
this with correct times inserted:

11 June 2022,1215

 D: States headache of 7 on 1–10 scale. Physical examination (assessment)

unremarkable.
 A: Tylenol, 650 mg, administered as ordered.
 R: States headache is now a 2 on 1–10 scale.
 T: Instructed to use call light if headache returns or develops other concerns.
__________________________________________________G. Nurse, RN

SBAR:

11 June 2022, 1215

 S: Reports headache of 7 on 1–10 scale.

 B: Has been admitted to hospital with diagnosis of pneumonia. Has been
reading without his glasses while hospitalized.
 A: Physical assessment unremarkable.
 R: Tylenol, 650 mg, administered as ordered.
_________________________________________________G. Nurse, RN

Documentation Example 1 (Poor Documentation):

11 December 2009, 1100: Vitals done. Physical assessment done. No problems

noted. Skin clear. Eyes and nose OK. Mouth moist. Hears. Heart regular. Lungs

114
 Faculty of Nursing- Damietta University

clear. Bowel sounds present. Pulses +2. Capillary refill present.

_____________________________________________G. Nurse, RN

WHY IS THIS DOCUMENTATION POOR?

This documentation is missing key details that would provide continuity of care. It
is also missing information, which means that it is not representing the accurate
portrayal of the full assessment performed by the nurse. Many general statements
are included, but the next nurse reading this documentation is left to ask:

■―What were the vital signs?‖

■―How well did the client hear?‖

■―How long did capillary refill take?‖

■―Which pulses were palpated?‖

The nurse has not documented the exact vital signs or the specifics of what was
found during the assessment. Even if findings are normal, it is important to record
what was specifically inspected, auscultated, palpated, and percussed.

Documentation Example 2 (Fair Documentation):

11 December 2009, 1100: Vital signs taken. T 99.0, P 82, R 16, BP 134/84.Skin
without lesions or breakdown. PERRLA. Nose patent. Mucous membranes moist.
Can hear. No JVD, no carotid bruits. Heart: regular rate and rhythm. Lungs clear to
auscultation. Bowel sounds normoactive in4 quadrants. Radial and pedal pulses
present. Strength equal. Capillary refill x 2 seconds.
_____________________________________G. Nurse, RN

WHY IS THIS DOCUMENTATION FAIR?

115
 Faculty of Nursing- Damietta University

This documentation is clearly better than the documentation found in Example 1,

as it includes more detail. The specific vital signs are listed, and the nurse has not
identified findings ambiguously by saying they are ―OK.‖ The nurse has also
clarified the location of the bowel sounds, describing them as normoactive, and has
completed the timing of capillary refill.

Documentation Example 3 (Good Documentation):

11 December 2009, 1100: T 99.0, P 82, R 16, BP 130/80 GR 134/84. Alert and
oriented x 3. Smiling and conversant. Skin warm and dry with pink under-tones
and without lesions or breakdown. PERRLA; wearing glasses. Nose patent.
Mucous membranes moist; wearing clean dentures. Can hear whispers. No JVD,
no carotid bruits. Heart: 82 and regular, no murmurs noted. Lungs clear to
auscultation; breathing easy and symmetrical. Abdomen soft and round, no
distended, no tender. Bowel sounds normoactive in 4 quadrants. Last bowel
movement yesterday; states ―it was normal.‖ No breast or vaginal discharge noted.
Radial and pedal pulses + 2 and equal. Strength equal in upper and lower
extremities. Capillary refill x 2 seconds. No edema noted. Bed in low position, 2
side rails up, call light in reach. ___________________________G. Nurse, RN

WHY IS THIS DOCUMENTATION GOOD?

In comparison with examples1 and 2, the nurse has clearly identified pertinent
findings about the client, and has included very specific clarifying phrases, such as
complete descriptions of heart rate and ease of breathing, as well as notation of the
pulses, commentary on extremity strength, and a description of how the client was
left. When the next shift‘s nurse comes on, he or she will be able to read this
documentation and know exactly what the nurse observed. This provides the best
basis for continuity of monitoring and care planning.

116
Faculty of Nursing- Damietta University

117
 Faculty of Nursing- Damietta University

References

 Blair, W. & Smith, B. (2012). Nursing documentation: Frameworks and

barriers. Contemporary Nurse, 41(2), 163.
 Cheevakasemsook, A., Chapman, Y., Francis, K., & Davies, C. (2006).
The study of nursing documentation complexities. International Journal of
Nursing Practice, 12, 366-374.
 Ashurst, A. (2000). Care documentation for the 21st century. Nursing and
Residential Care, 2(11), 542-544.
 College of Nurses of Ontario (CNO). (2002). Nursing documentation
standards. Toronto, Ontario Canada: Author
 College of Registered Nurses of British Columbia (CRNBC). (2012).
Practice support: nursing documentation. Vancouver, BC Canada: Author
 Griffiths, R., Jeffries, D., & Johnson, M. (2010). A meta-study of the
essentials of quality nursing documentation. International Journal of Nursing
Practice, 16, 112-124.
 Paans, W., Sermus, W., Nieweg, R. & van der Schanns, C., (2010).
Prevalence of accurate nursing documentation in patient records. Journal of
Advanced Nursing, 66(11), 2481-2489.
 Warren, A. & Creech-Tart, R. (2008). Fatigue and charting errors: the
benefit of a reduced call schedule. Association of Perioperative Registered
Nurse (AORN) Journal, 88(1), 88-95.
 World Health Organization (2013). Exploring patient participation
reducing health care related safety risks. Retrieved August 1, 2013.
 Brenner, Z.R., Dimitroff, L. J., & Nichols, L.W. (2010). Documentation
of nursing care behaviors. International Journal for Human Caring, 14(4):7-
13.

118
 Faculty of Nursing- Damietta University

 Brunetti, L., Hicks, R., & Santell, J. (2007). The impact of abbreviations
on patient safety. The Joint Commission Journal on Quality and Patient
Safety, 33(9), 576-583.
 College of Registered Nurses of British Columbia (2012). Practice
Support - Nursing Documentation. Retrieved February 14, 2014, from
http://www.crnbc.ca
 Mosby-Elsevier. (2006). Mosby‘s surefire documentation –how, what, and
when nurses need to document (2nd ed.). St. Louis, MO: Author
 Lippincott, Williams & Wilkins. (2006). Charting made incredibly easy
(3rd ed.) Philadelphia, PA: Author
 Toronto, Ontario: York University, Osgoode Law School (2013). Legal
risk management in documentation and charting for nurses.
 Canadian Nurses Protective Society. (2013). Info law – mobile devices in
the workplace. Retrieved April 30, 2014, from http://www.cnps.ca
 Canadian Nurses Protective Society. (2014). The electronic health record by
Jim Anstey. Webinar June 11, 2014 on http://www.cnps.ca
 Kelley, T.F., Brandon, D.H., & Docherty, S.L. (2011). Electronic nursing
documentation as a strategy to improve quality of patient care. Journal of
Nursing Scholarship, 43(2), 154 – 162.
 Kutney-Lee, A. & Kelly D., (2011). The effect of hospital electronic health
record adoption on nurseassessed quality of care and patient safety. The
Journal of Nursing Administration, 41(11), 466-472.
 Laitinen, H., Kaunonen, M., & Astedt-Kurki, P. (2010). Patient-focused
nursing documentation expressed by nurses. Journal of Clinical Nursing, 19,
489-497.
 Lippincott Williams & Wilkins. Lippincott Williams & Wilkins. (2009).
Nursing know how – charting patient care. Philadelphia, PA:
 Lippincott Williams & Wilkins. Mosby. (2006). Mosby‘s sure-fire
documentation: How, what, and when nurses need to document. St Louis,
MO: Mosby Elsevier
 Wilkinson, J. & Treas, L. (2011). Fundamentals of nursing – theory,
concepts and applications (2nd ed.). Philadelphia, PA: F. A. Davis Co.

119