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Published by cikgu online, 2020-01-20 21:08:50

INTRODUCTION OF NURSING 1.4 The Nursing Process (PART 3)


1.4 The Nursing Process





4. Documentation

• Principles of documentation


➢Correction / omissions



➢Accountability / signature




4. Documentation

• Content of documentation


➢Accurate, Concise and precise



➢Type of entries

✓Admission note

✓Progress note

✓Client reaching notes

✓Observation notes

✓Medication and treatment notes



4. Documentation

• Documentation format

➢Narrative notes

➢SOAP notes

➢PIE notes

➢Focus charming

➢Charting by exception

➢Case management models

➢Electronic documentation





• Important role of the medical

➢assure that the high quality patient care you provide is documented in a clear and

concise manner.

➢documentation principles which apply whether relies upon electronic documentation,

paper-based documentation, or a combination of the two systems.

➢lapses in applying these principles may create complications when documentation is

presented as evidence to defend against allegations of malpractice, negligence, or

failure to meet standards of care.



➢By concentrating on the principles of documentation your documentation will reflect

the quality care you provide and reduce the risks of a lawsuit.

➢One of the cardinal principles of legally defensible documentation is adherence to

organizational policy and procedures (P&P), standards of care, guidelines,
competencies, and any other organizational document that guides the care of patients.

➢The reasons for deviation from these documents must be clearly supported in the
medical record.



1. Principles of documentation

2. Content of documentation

3. Documentation format

Principles of




When a medical record is examined in a

malpractice or negligence case, date and

time are critical in establishing a timely

response to a patient need.

Resist the temptation to leave ➢You may forget key pieces of

documentation until the end of the shift information when rushing



• Charting as your shift progresses will help keep your documentation


➢Professionals in other disciplines and nurses who provide temporary coverage need

to have up-to-date information available in the record

➢Other professionals who access the record need to have up-to-date data to guide


• Computer entries are automatically date-and-time stamped

➢When your entry refers to earlier events, note the time to which you are referring

NEVER document in advance. This practice is illegal falsification of the record


• The important factors to remember when correcting a

documentation error is to be very clear what the error
was and what the correct information should be.

• Electronic records:
Correction / ➢ Each system has specific methods for correcting

errors. Assure that you know the proper

Omissions procedure for the system that you are using.

• Paper records:

➢ A single line should be drawn through the error

➢ The correct information should be entered legibly

➢ The date, time, and initials of the person
correcting the documentation should be present


Error Prevention Technical Tips

• Use the appropriate form or screen.

• Document in ink.

• Verify that the correct patient’s name and ID number are on every page of the chart.

• Record the complete date and time of each entry.

• Use only standard, organization-approved abbreviations, acronyms, and symbols.

• Use a medical term only if you are sure of its meaning.


Error Prevention Technical Tips

Document symptoms
by using the patient’s Document objectively. Write legibly.
own words.

If you replace a page

Locate and orient on which information
yourself to all has been recorded, Write on every line.

interdisciplinary forms, retain the original and Leave NO blanks.
progress notes, and place it in the medical

flow sheets. record according to


Error Prevention Technical Tips

If you chart on the

Chart any wrong chart, omit

omission or late information, or need to

entry as a new amend a chart at a
Sign your full entry. Do not later time, carefully

name and title.
backdate or add follow your

to previously organizational policy

written notes. for performing these




Unfortunately, abbreviation use is
Abbreviations are
responsible for increased errors. Your
commonly used among
institution should provide you with a
healthcare workers as a
list of acceptable abbreviations for use
time saving methodology.
in documentation.

Use correct terminology to Avoid using abbreviations that are

avoid error not registered internationally



• Use only universally accepted abbreviation e.g. P.R.N., B.D. and not S.O.B., CRIB, as this is

only confined to some hospitals only.

• Keep to essentials without sacrificing significant information.

• E.g:

• “To do tepid sponge if Temperature rises above normal level” is superfluous (berlebihan)
and vague. It is preferred to write, “Tepid sponge if Temperature is above 39C.



Format of documentation are Example documentation

varies follows the practice of format that been use in

the hospital. Malaysian hospital includes

• Narrative


• Electronic documentation


Accountability / Signature

Nurses are

accountable for

ensuring their


of client care is


timely and




• The nurse is responsible for protecting privacy & confidentiality of client interactions,

assessment, & care.

• Client’s significant others, insurance companies, or other parties not directly involved in
care provided by the health team may not have access to client’s records.


Content of documentation


High quality documentation is:

1. Accessible

2. Accurate, relevant, and consistent

3. Auditable

4. Authenticated/Author identified

5. Clear, concise, and complete

6. Date and time stamped

7. Legible/readable

8. Thoughtful

9. Timely, contemporaneous, and sequential

10. Reflective of the nursing process

11. Retrievable on a permanent basis in a nursing-specific manner


Content of Documentation

F = Factual

A = Accurate

C = Complete

T = Timely


F = Factual

• Only information you see, hear, or otherwise collect through your senses

• Describe, don’t label

• Describe behavior, not conclusions such as “confused,” “drunk,” or “violent”

• State facts, not value judgments such as “No change” “Ate well”

• Be specific

• Use neutral language

• Avoid bias


F = Factual

• When you make an error:

➢State exactly what you did or failed to do

➢State that you notified the patient’s provider, and the provider’s response

➢Do not state “by mistake” or explain how the error occurred

➢Report this occurrence on the incident report (or form your organization uses for error

documentation) and to relevant staff members


A = Accurate

• Be precise

• Quantify whenever possible

• Be sure to make clear who gave the care

• When countersigning with a student or another nurse, review the content of the

documentation and document your own follow-up assessment, interventions if any, and
the patient’s response


C = Complete


• Condition change

• Patient responses, especially unusual, undesired or ineffective response

• Use of chain-of-command

• Communication with patient and family

• Entries in all spaces on all relevant assessment forms

➢Use N/A or other designation for items that do not apply to your patient


➢Blanks are hazardous because they permit entries above your signature

➢Others may make entries in such blanks by mistake or to purposely falsify records

T = Timely

• When a medical record is examined in a malpractice or negligence case, date and time are

critical in establishing a timely response to a patient need.

• Resist the temptation to leave documentation until the end of the shift

• You may forget key pieces of information when rushing

• Charting as your shift progresses will help keep your documentation accurate


T = Timely

• Professionals in other disciplines and nurses who provide temporary coverage need to have

up-to-date information available in the record

• Other professionals who access the record need to have up-to-date data to guide care

• Computer entries are automatically date-and-time stamped:

➢When your entry refers to earlier events, note the time to which you are referring

➢NEVER document in advance o This practice is illegal falsification of the record


Type of entries

Admission Progress

note note


Admission note

• Receiving/admission notes are based on a patient’s initial assessment at ahealthcare


• In this case, the nurse collects first-hand information that s/he notes down and passes on
to other nurses or physicians.

• Receiving/admission notes should include

➢Patient’s history, general appearance, physical examination and vital signs completed
at the time of admission


Progress note

• Taber's medical dictionary

➢An ongoing record of a patient's illness and treatment.

➢Physicians, nurses, consultants, and therapists record their notes concerning the
progress or lack of progress made by the patient between the time of the previous

note and the most recent note.


Progress note

• Mosby's medical dictionary defines

➢Notes made by a nurse, physician, social worker, physical therapist, and other health

care professionals that describe the patient's condition and the treatment given or



Handover Notes

• notes are written by nurses as they transition in or out of their shift.

• They provide nurses, who are taking over the care of your patients, with key information

about a patient’s condition, treatment etc.

• Handover notes are very important because they pass on critical knowledge about your
patient to the incoming nurse.



Discharge Notes

• Discharge notes are written when a patient is being discharged from a

healthcare facility.

• Generally, discharge notes are a combination of information including

patient conditions, treatment history, healthcare provider details, as well as

15 post-discharge plans and arrangements.

• These notes may be used by other healthcare providers.


1. Failure to record pertinent health or drug

2. Failure to record nursing actions

3. Failure to record administered


Common 4. Documentation in the wrong patient’s

medical record

Charting Errors 5. Failure to record discontinued medications

6. Failure to record drug reactions

7. Failure to record changes in the patient’s


8. Transcription errors

9. Illegible or incomplete Records


Documentation format


a. Narrative Note

• Describes the client’s status, interventions and treatments; response to treatments is in

story format.

• Narrative charting is now being replaced by other formats.


b. SOAP Notes

What is a SOAP Note?

• information about the patient, which is written or presented in a specific order

includes certain components.

• used for admission notes, medical histories and other documents in a patient’s


• Structure

➢The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan.


SOAP Notes

1. Subjective

• This is the first heading of the SOAP note.

• Documentation under this heading comes from the “subjective”

experiences, personal views or feelings of a patient or someone

close to them.

• In the inpatient setting, interim information is included here.

• This section provides context for the Assessment and Plan.


SOAP Notes - Subjective

a. Chief Complaint (CC)

• The CC or presenting problem is reported by the patient.

• This can be a symptom, condition, previous diagnosis or another short

statement that describes why the patient is presenting today.

• The CC is similar to the title of a paper, allowing the reader to get a sense of

what the rest of the document will entail.

• Examples: chest pain, decreased appetite, shortness of breath.


SOAP Notes - Subjective

b. History of Present Illness (HPI)

• The HPI begins with a simple one line opening statement

including the patient's age, sex and reason for the visit.

• Example: 47-year old female presenting with abdominal pain.


SOAP Notes - Subjective

• This is the section where the patient can elaborate on their chief complaint. An acronym

often used to organize the HPI is termed “OLDCARTS”:

➢Onset: When did the CC begin?

➢Location: Where is the CC located?

➢Duration: How long has the CC been going on for?

➢Characterization: How does the patient describe the CC?

➢Alleviating and Aggravating factors: What makes the CC better? Worse?

➢Radiation: Does the CC move or stay in one location?

➢Temporal factor: Is the CC worse (or better) at a certain time of the day?

➢Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the 44

patient rate the CC?

SOAP Notes - Subjective

3. History

• Medical history: Pertinent current or past medical conditions

• Surgical history: Try to include the year of the surgery and surgeon if possible.

• Family history: Include pertinent family history. Avoid documenting the medical

history of every person in the patient's family.

• Social History: An acronym that may be used here is HEADSS which stands for

Home and Environment; Education, Employment, Eating; Activities; Drugs;

Sexuality; and Suicide/Depression.


SOAP Notes - Subjective

4. Review of Systems (ROS)

• This is a system based list of questions that help uncover

symptoms not otherwise mentioned by the patient.

• General: Weight loss, decreased appetite

• Gastrointestinal: Abdominal pain, hematochezia

• Musculoskeletal: Toe pain, decreased right shoulder range of



SOAP Notes - Subjective

5. Current Medications, Allergies

• Current medications and allergies may be listed under the

Subjective or Objective sections. However, it is important that

with any medication documented, to include the medication

name, dose, route, and how often.

• Example: Motrin 600 mg orally every 4 to 6 hours for 5 days


SOAP Notes - Objective

• This section documents the objective data from the patient encounter.

• This includes:

➢Vital signs

➢Physical exam findings

➢Laboratory data

➢Imaging results

➢Other diagnostic data

➢Recognition and review of the documentation of other clinicians.


SOAP Notes - Objective

• A common mistake is distinguishing between symptoms and signs.

• Symptoms are the patient's subjective description and should be

documented under the subjective heading, while a sign is an objective

finding related to the associated symptom reported by the patient.

• An example of this is a patient stating he has “stomach pain,” which is a

symptom, documented under the subjective heading.

• Versus “abdominal tenderness to palpation,” an objective sign documented

under the objective heading.


SOAP Notes - Assessment

• This section documents the synthesis of “subjective” and

“objective” evidence to arrive at a diagnosis.

• This is the assessment of the patient’s status through analysis of

the problem, possible interaction of the problems, and changes

in the status of the problems.


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