Professional Documents
Culture Documents
in Nursing
Documentation is anything written or printed that is relied on as a record of proof for
authorized persons. Documentation and reporting in nursing are needed for continuity of
care it is also a legal requirement showing the nursing care performed or not performed
by a nurse.
Purposes
1. Communication
2. Planning Client Care
3. Auditing Health Agencies
4. Research
5. Education
6. Reimbursement
7. Legal Documentation
8. Health Care Analysis
Documentation Systems
1. Database – consists of all information known about the client when the client
first enters the health care agency. It includes the nursing assessment, the
physician’s history, social & family data
2. Problem List – derived from the database. Usually kept at the front of the
chart & serves as an index to the numbered entries in the progress notes.
Problems are listed in the order in which they are identified & the list is
continually updated as new problems are identified & others resolved
3. Plan of Care – care plans are generated by the person who lists the problems.
Physician’s write physician’s orders or medical care plans; nurses write
nursing orders or nursing care plans
4. Progress Notes – chart entry made by all health professionals involved in a
client’s care; they all use the same type of sheet for notes. Numbered to
correspond to the problems on the problem list and may be lettered for the
type of data
Example: SOAP Format or SOAPIE and SOAPIER
S – Subjective data
O – Objective data
A – Assessment
P – Plan
I – Intervention
E – Evaluation
R– Revision
Advantages of POMR:
It encourages collaboration
Problem list in the front of the chart alerts caregivers to the client’s needs &
makes it easier to track the status of each problem.
Disadvantages of POMR:
4. Focus Charting
a. Intended to make the client & client concerns & strengths the focus of care
b. Three (3) columns for recording are usually used: date & time, focus & progress notes
5. Charting by Exception
Documentation system in which only abnormal or significant findings or
exceptions to norms are recorded
Incorporates three (3) key elements:
o Flow sheets
o Standards of nursing care
o Bedside access to chart forms
6. Computerized Documentation
Developed as a way to manage the huge volume of information required in
contemporary health care
Nurses use computers to store the client’s database, add new data, create &
revise care plans & document client progress.
7. Case Management
Emphasizes quality, cost-effective care delivered within an established length
of stay
Uses a multidisciplinary approach to planning & documenting client care,
using critical pathways.
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1. Traditional Care Plan – written for each client; it has 3 columns: nursing diagnoses,
expected outcomes & nursing interventions.
2. Standardized Care Plan – based on an institution’s standards of practice; thereby
helping to provide a high quality of nursing care
KARDEX
Widely used, concise method of organizing & recording data about a client,
making information quickly accessible to all health professionals. Consists of a
series of cards kept in a portable index file or on computer generated forms.
Information may be organized into sections:
http://nurseslabs.com/documentation-reporting-in-nursing/