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Documentation

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Aseel NK
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11 views

Documentation

Uploaded by

Aseel NK
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Documentation

general documentation guidelines

All documentation must be legible.

 All entries into the medical record must be made in


indelible ink, either black or blue. No pencil entries are
allowed.

 no skipped lines or spaces


 in error should be marked through with a single line.

 Only approved medical abbreviations should be used in


documentation entries
Only those individuals permitted by medical staff 
bylaws, rules and regulations are allowed to perform
and document assessments and reassessments of
. patients in the inpatient and outpatient

For nurses :Registered nurses are the one who 


permitted to document nursing assessments,
reassessments care plan, & pain assessment of the
.patients in the inpatient and outpatient settings
 Any verbal /telephone order should be documented according to the
VERBAL ORDER

 Signature and professional title (MD, RN, ) , first, last name, &
signature. If two names is identical first and second and family
name should be used .

 late entry is made, the author must write "Late Entry" and the
actual date and time of the entry along with reference information.
 Nursing students/trainees are not allowed to
document in the patient chart.

 Nurse document only for care they provide directly.


What should be documented

 An initial nursing assessment documented within 4 hours


of patient admission, or earlier as required by the patient's
condition and unit of admission.
 Nursing reassessment :

- should be documented in the medical record within 2


hours:
- changing shift.

- when there is significant change in the patient


condition and immediately after surgery or invasive
procedure.

- To evaluate response to treatment.


Nursing care plan

A: list of problems or change. List of


problem will be identified based on
subjective and objective data.
P: Planning: the nurse plan how to deal
with the identified problem (e.g., is the
plan the same? Is a change needed?)
I: Intervention (e.g., what occurred?
What did the nurse do?)
E:Evaluation (e.g., did the plan work? Are
changes needed?)
 Progress notes by the medical staff every 24
hours or more frequently indicating the
patient's status and response to treatment.

 Any changes on patient condition , treatments ,


and response to treatment should be
documented .

 Reassessment should be done whenever


patient’s level of cares changed .
An indication of discharge planning from the
initial assessment and subsequent
reassessments

Every medication ordered or prescribed for a


patient, time of administration, and any
adverse reactions
 Consultation notes must be documented within 24
hours of referral .

 Signed general consent for treatment upon admission


to the hospital.

 Signed and witnessed informed consent for all


invasive, or high risk procedures, as defined by
Specialty Hospital policy
 Patient discharge instructions .

 Note related to nutrition: An order for food / diet,


nothing by mouth, parenteral or enteral nutrition is
documented for each patient

 Follow up instructions .
 Surgical patients should have medical and nursing
initial assessment performed and documented in
patient’s medical record prior to surgery.

 Surgical care is planned and documented based on


the results of initial assessment

 A pre-operative diagnosis is documented


 In surgical emergencies, the initial medical
assessment may be limited to the patient’s apparent
needs and condition, if surgery is performed there
should be at least brief note and preoperative
diagnosis recorded before surgery.

 ( preoperative checklist , consent form , pre-


operative anesthesia assessment )
Transfer to another institution,
documentation requirement

 Name of receiving institution


 Reason for transfer
 Any special conditions related to the transfer
 Any change in the patient’s condition or status during the
transfer
 A full discharge summary should accompany all inpatient
transfers
Transfer to another unit within the hospital

 Reason for transfer


Summary of hospital course until time of transfer
Transfer orders
Patient education and follow up instruction

 Follow-up instructions are provided written and verbally


and in a form and language the patient can understand.
Guidelines for Pain
Pain is assessed and documented:

- Upon admission or presentation for care.

- At least every shift.

- At the time of patient’s report of pain.

- Before and after any intervention provided for


relief of pain (see pain assessment and management
policy).

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