DOCUMENTATION

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meaning

any written or electronically generate d information about a client that des cribes the care or service provided to that client. The process of making an entry on a client record is called recording, char ting or documenting.

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DEFINITION

Documentation is any written or ele ctronically generated information abo ut a client that describes the care or service provided to that client. Health records may be paper docume nts or electronic documents, such as electronic medical records, faxes, emails, audio or video tapes and imag es.

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Purposes of documenting:

Purposes of documenting:

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Communication:

between nurses and other care providers prevents fragmentation, repetition, and delays in client car e. Accurate documentation decreases the potential for misco mmunication and errors. encourages nurses to assess client progress determine which interventions are effective and which are ineffective, identify and document changes to the plan of care as need ed.

Planning client care:

Auditing health agencies Research:

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to improve the quality of nursing practice and client care.

Education:

provide a comprehensive view of the clie nt, the illness, effective treatment strate gies, and factors that affect outcome of an illness. to obtain payment through Medicare, reveals that the appropriate care has be en given.

Reimbursement:

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Legal documentation:

supports nurses to meet professional and legal standards. used as evidence in legal proceedings such as lawsuits, c oroners inquests, and disciplinary hearings In a court of law, the clients health record serves as the l egal record of the care or service provided. use outcome information or information from a critical inc ident to reflect on their practice and make needed change s based on evidence. Records may assist healthcare planners to identify agenc y needs, such as over utilized or underutilized hospital se rvices.

Health Care Analysis:

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Guidelines for recording:

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Date and time:

Document the date and time of each recording. Maybe recorded as per 12 hour or 24 hour clock. done as soon as possible after an assessment or interve ntion. No recording should be done before providing nursing c are. must be legible and easy to read to prevent interpretatio n errors. Easily understood hand writing is usually permissible.

Timing:

Legibility:

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Permanence:

made in dark ink so that the record is pe rmanent and changes can be identified. Follow the agency policy about the type of pen and ink used for recording. use only commonly accepted abbreviatio ns, symbols and terms that are specified by the agency.

Accepted terminology:

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Abbreviation Abd ABO ADL AM ECG WNL Wt

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Term Abdomen Main blood group system Activities of daily living Morning Electrocardiography Within normal limits Weight

Correct spelling: Signature:

The signature includes name and title; for eg, Susan J Green, RN or SJ Green, RN. With computerized charting, each nurse has his or her own code, which allows the documentatio n to be identified.

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Accuracy:

the clients name and identifying information sh ould be stamped or written on each page of the clinical record. Do not identify charts by room number only; check the clients name. Notations on records must be accurate and cor rect. They consist of facts or observations rather tha n opinions or interpretations. It is preferable to write a client was crying rather than the client was depressed.

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When a recording mistake is made,

draw a line through it and write the words mistaken entry above or next to the original entry, with your initials or name. Do not erase, blot out or use correction fluid. The original entry must remain visible. If a blank appears in a notation, draw a line thr ough the blank space so that no additional infor mation can be recorded by any other person, an d sign the notation.

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Sequence:

Document events in the order in which they occur.

Appropriateness: Completeness:

Record all assessments, dependent and independent nur sing interventions, client problems, client comments and responses, progress towards goals, and communication with other members of the health team. Care that is omitted ( not performed) because of the clie nts condition or refusal of treatment must also be recor ded. Document what and why it was omitted and who w as notified.

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Conciseness:

brief as well as complete to save time in communications . The clients name and the word client are omitted. Accurate, complete documentation should give legal prote ction to the nurse; the clients other caregivers, the healt hcare facility, and the client. Adhere to the professional standards of nursing care follow agency policy and procedures for interventions and documentation in all situations.

Legal prudence:

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