DOCUMENTATION

PRESENTED BY: SR JULIAN KAVILI

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LEARNING OBJECTIVES
By the end of the lesson the learner will be
able to:

1. Define of documentation/nursing
documentation
2. Outline types of communication in health
care sector
3. Explain ethical and legal considerations in
documentation
4. Explain the importance of documentation
5. Outline the variety of documents used in
nursing documentation 2
 Definition
 Documentation is anything written or

electronically generated that

describes the status of a patient or
the care or services given to that
client (Perry, A.G., Potter, P.A., 2010).
 Nursing documentation refers to

written or electronically generated

patient information obtained through
the nursing process (ARNNL, 2010).
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 Effective communication among
health professionals is vital to the
quality of patients care. Health
personnel communicate through
discussions, reports and records.
 A discussion is an informal oral

communication by two or more

health care personnel to identify a
problem or establish strategies to
resolve a problem.

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A report is oral, written or
computer based communication
intended to convey messages to
the others. For example, a nurse will
always report on the patients at the
end of every working shift.
 A record is a written or computer

based report of the patient.

 Recording, charting, or

documenting is the process of

making an entry on a patient’s
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record.
Aclinical record also called a chart
or a patient’s record is a formal,
legal document that provides
evidence that patient care has been
given.
Different health care institutions use
different systems and different forms
of documentation but all patient’s
records have similar information.

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Every health care organization has
policies about recording and
reporting patients data and each
nurse is accountable for practicing
according to these standards.

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 ETHICAL AND LEGAL
CONSIDERATIONS
 Confidentiality

The nurse has a duty to maintain

confidentiality of all patient
information.
 Privacy

The patient record is a private record

to the clients care. Access to the
record is restricted to the health
professionals involved in the giving 8
care to that particular patient.
 PRINCIPLES OF DOCUMENTATION
Nursing documentation must provide an
accurate and honest account of what and
when events occurred, as well as identify
who provided the care.
Good documentation has six important
characteristics. It should be:
factual
accurate
complete
current (timely)
organized
compliant with standards 9
IMPORTANCE OF DOCUMENTATION
Clear, complete and accurate
patient’s records serve many
purposes for the patient, families,
nurses and other care providers.

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 Communication and Continuity of
Care
 Patients records serve as a means of

communication through which

different health professionals who are
taking care of the patient
communicate with each other.
 This prevents in fragmentation,

repetition and delays in the care of

the patient.
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 Planning patients care
 Each health professional uses data

from the patients record to plan for

the care of that patient. For example,
a doctor may order a specific type of
antibiotic for a patient after
establishing that the laboratory tests
reveals the presence of a certain
microorganism.
 Nurses uses baseline and ongoing

data to evaluate the effectiveness of

the nursing care plan. 12
 Accountability
 Nurses have the responsibility to

apply nursing knowledge and skills in

providing safe, competent and ethical
nursing care.
 Patients records reflect accountability

for the care provided by the

particular nurse. Every nurse should
only document their own
observations and nursing care given.

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 Documentation on the patient’s
record is an indication of the care
given to the patient and makes a
nurse visible.
 Always remembers “NOT

DOCUMENTED , NOT DONE”

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 Legal purposes
 The patient’s records is legal document

and is usually admissible in court as

evidence.

Education
 Students in health disciplines often uses

patients records as education tools. The

patients record should have a
comprehensive view of the client, the
illness, effective treatment strategies and
factors that affect the outcome of the
illness. 15
 Research
 The information contained in a

patient’s records can be a source of

data for research.
 The treatment plans for a number of

patients with the same health

problems can yield information
helpful in treating other patients.

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 Auditing heath facilities
 An audit is a review of patients

records for quality assurance

purposes.
 Professional bodies like Nursing

Council of Kenya may conduct some

audit on the patients records to
determine if a particular health
institution meeting its stated
standards.
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 Health care analysis
 Information from patients records

may assist health care planners to

identify health care facility needs
such as over-used or under-used
hospital services.
 These records can be used to

establish the cost of various health

services. This will help to identify
those health care services that cost
the health institution money and 18

those that generate revenue.

 Reimbursement/ funding
 Documentation helps a health facility

receive reimbursement from the

government or the insurance
companies or any other third party
payers.
 Nursing services done on any

particular patient, treatment given, or

length of hospital stay should be well
charted to justify the funding.
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 Patient teaching
 By proper documentation, the nurses

can be able to provide education to

the patients about their health
conditions and how to take care of
themselves when outside the health
care facility.
 Accurate documentation of this

education is essential to enable

communication and continuity of
what has been taught.
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DOCUMENTING NURSING ACTIVITIES
Documentation usually begins with
date and time and ends with the
recorder’s name, signature and
designation.
The clients record should describe
the clients ongoing status and reflect
the full range of nursing process.
Nurses document is the evidence of
the nursing process on a variety of
forms throughout the clinical records.21
VARIETY OF DOCUMENTS USED IN
NURSING DOCUMENTATION

Admission nursing assessment

It is also referred to as initial
database, nursing history, or nursing
assessment.
It is completed when the patient is
admitted to the nursing unit.
The nurse generally records ongoing
assessments or reassessments on
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flow sheet or on nursing progress
notes.
Nursing care plans
This document includes evidence of
clients assessments, nursing
diagnosis, plan of action,
interventions and the evaluation.
Nursing care plans must be
individualised by the nurse in order
to adequately address individual
patients needs.

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 Kardex
This is a widely used, concise method
of organizing and recording data
about a patient, making information
quickly accessible to all health
professionals.
The cards of a particular patient can
be quickly accessed to reveal specific
data.
These forms can be hand written or
computer generated.
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 Any nurse who cares for the patient
plays a key role in initiating the
kardex and keeping the current data.
 It is a quick visual guide to ensure

that information is current and

updated on regular basis.

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Graphic Records/ observation
charts
This record typically indicates the
patients body temperature, pulse,
respirations, blood pressure, weight
and other significant clinical data like
admission date, post operative day.

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Intake and Output Record / Fluid
Chart

This is used to document all the fluids

administered or taken by the patient.
All routes of fluid intake and all routes
of fluid loss or output are measured
and recorded on this form.

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Medication Administration
Record/treatment sheets

Medication flow sheet usually include

designated areas for the date of
medication order, the medication
name and dose the, expiration date,
the frequency of administration and
route and the nurses signature.
It may also include a place to
document the patient’s allergies.
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Skin Assessment Record
These are the records related to
stage of skin injury, drainage, odor,
culture information and the
treatments.

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Nursing discharge /referral
summaries
A discharge note or a referral
summary are completed when the
client is being discharged or
transferred to another institution or
to a home setting where a visit or
follow up by a community health
nurse is required.
Many health institution provide
discharge forms or referral forms to
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be filled up.
GENERAL GUIDELINES FOR
DOCUMENTATION

Patient’s record is a legal document

and may be used to provide evidence
in court. Therefore health personnel
must not only maintain the
confidentiality of the patient's record
but also meet the following legal
standard in the process of recording.
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 Dateand time
Each document should have a
date and time of each recording.
The time should be recorded in a
convectional manner e.g. 6:20AM
or according to 24-hour clock.

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 Timings
Different heath institutions have
follow different frequencies for
documentation.
The frequency can also be
adjusted according to the patients
condition e.g., a patient who has
high temperatures requires
frequent documentation than a
patient with a normal
temperature.
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 Documentation should be done as
soon as soon as possible after
assessment or intervention.
NOTE: No recording should be
done before providing the nursing
care.

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 Legibility

All entries must be legible and

easy to read to prevent
interpretation errors.
 Permanence

All entries on the patients records

are permanent. Any changes
made should have the name and
signature of the person who made
the changes.
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 Accepted terminology
Use only commonly accepted
abbreviations, symbols, and
terms that are accepted by the
heath institution. This helps to
prevent confusion.
There are many abbreviations
that are standard and are used
universally.
If in doubt about a certain
abbreviation, write the term in
full.
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 Correct spelling
This is essential for accuracy in
recording. Always confirm that
you have used the correct
spelling for a particular word.
Incorrect spelling gives a negative
impression to the reader and
therefore decreases the nurses
credibility.

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 Signature

Each recording on the nursing

notes is signed by the nurse
making it. This signature includes
the name, and the designation of
the nurse who is doing the
recording.

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 Accuracy

The patient’s name and

identifying information should be
written on each page of the
clinical record.
Before making any entry, check
that it is the correct chart. Do not
identify charts by room numbers
only but always check the
patients name.
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Always record the facts and
observations rather than the
opinions, e.g., write “the patient
refused medication” but not “the
patient was uncooperative.”

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 Sequence

Documentation should be done of

events in the order in which they
occur.
 Appropriateness

Record only the information that

pertains to the patients health
problem and care.

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 Completeness

The information that is recorded

need to be complete and helpful
to the patient and the health care
professionals. Nurses need to
reflect the nursing process.
Care that is omitted because of
the patients condition or patient
refused, must be recorded.

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 Conciseness

Recording need to be brief and

complete to save time in
communication.
 Legal prudence

Accurate, complete
documentation should give legal
protection to the nurse, patient’s
other caregiver and the heath
care facility. The clinical record
provides a proof of the quality of 43

care given to the patient.

REPORTING
Reporting is done to
communicate specific information
to a person or a group of people.
A report whether oral or written
should be concise and having the
relevant information.

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 Change of shift report

This is given to all nurses in the

next shift. It is given to provide
continuity of care for clients by
providing the new nurses a quick
summary of clients needs and
details of care to be given.

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Change of shift report may be
written, or given orally.
It is either given at bedside or in a
private and free from interruption
area in order to maintain privacy.

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 Telephone reports
Health professional may report
about a client by telephone. E.g. a
nurse may report about a change
in a patient’s condition, a
radiologist may report the results
of an x-ray study.
The nurse receiving this telephone
report should document the time,
the name of the person giving the
information, the subject of the
information received and his/her 47

signature.
QUESTIONS

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GENERAL GUIDELINES FOR
INTERVIEWING PATIENTS
Use an opening greeting (i.e., Good
afternoon, How are you today?)
 2. Introduce yourself. (Use your name, state

your relationship to Dr. ______ and your role

in the office)
 Use open-ended questions to initiate the

interview such as: “What brings you here

today?” or “What can I do for you today?”
 Allow the patient enough time to tell his/her

story
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 Ask questions to clarify the information
given. These are the typical components of
the history of present illness.
 For example: When did it start?

 How did it start?

 Has it become better or worse?

 How severe is it?

 Does anything help you feel better?

 Does anything make you feel worse?

 Do you have any other symptoms?

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 Ask other questions that you think may help
narrow down the differential diagnosis
 Ask more specific questions that you think

are important. Consider asking about

potential risk factors for diseases that could
be causing the patient’s symptoms.
 Use some of the skills of communicating with

patients to elicit the patient’s concerns and

demonstrate empathy.

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 Conclude the interview (e.g. “I think I
understand your concerns. I am going to talk
to Dr. ______ and we will both be back in to
see you shortly. I’m sure she/he will have
more questions for you.”)

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