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Effective Nursing Documentation Guide

Proper documentation is a vital aspect of nursing practice. Effective documentation requires following certain principles - the requirements can vary depending on healthcare setting, and documentation must be logical, focused on care outcomes, and follow the nursing process. Documentation serves several important purposes - it communicates information, provides education, allows for research and quality evaluation, establishes a legal record, and supports reimbursement. Common methods of documentation include narrative charting, problem-oriented charting using formats like SOAP, focused charting using FDAR, and computerized documentation.

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Kate Lagundi
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116 views2 pages

Effective Nursing Documentation Guide

Proper documentation is a vital aspect of nursing practice. Effective documentation requires following certain principles - the requirements can vary depending on healthcare setting, and documentation must be logical, focused on care outcomes, and follow the nursing process. Documentation serves several important purposes - it communicates information, provides education, allows for research and quality evaluation, establishes a legal record, and supports reimbursement. Common methods of documentation include narrative charting, problem-oriented charting using formats like SOAP, focused charting using FDAR, and computerized documentation.

Uploaded by

Kate Lagundi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Proper Documentation:

DOCUMENTATION

• Anything written or printed that serves as a record or proof of authorized persons.


• Vital aspect of nursing practice.

Principles of Effective Documentation


1. Documentation requirements differ depending on the:
￮ Health care facility
￮ Setting
￮ Client
2. Must be:
￮ Logical
￮ Focused and relevant to care
￮ Outcomes must represent each phase of the nursing process

Elements of Effective Documentation


1. Use common vocabulary – improves intra team vocabulary and lessen
misunderstanding
2. Follow factual and time sequenced organization
3. Write legibly and neatly – lessens the chance of errors
4. Use authorized abbreviations and symbols
5. Document accurately (factual, descriptive, observations); including any ERRORS that
occurred
****Treat all client information in CONFIDENTIAL and PROFESSIONAL MANNER
Purpose of Health Care Documentation
1. Communication
▪ it validates the care provided to the client
2. Education
▪ Provides valuable information regarding specific diagnoses and interventions
3. Research
▪ Determined if client meet the research criteria of a study
4. Legal and Practice Standards
– Legal document and determines factors in providing proof of significant events.
5. Reimbursement
– Review to monitor and evaluate the quality and appropriateness of care given
Methods of Documentation

￮ Narrative Charting

￮ Traditional method

Batch2023/tfn/1stsem/sy2019_2020/rlp
￮ A story format

￮ Source-Oriented Charting

￮ Narrative recording by each member of the health team on separate records.

￮ Problem-Oriented Charting

￮ SOAP (Subjective, Objective, Analysis, Planning)

￮ SOAPIE (Subjective, Objective, Analysis, Planning, Intervention, Evaluation)

￮ SOAPIER (Subjective, Objective, Analysis, Planning, Intervention, Evaluation,


Re-evaluation)

￮ Focused Charting

￮ Includes data, action and response.

￮ FDAR (Focus, Data, Action, Response)

￮ Pie Charting

￮ On-going plan of care.

￮ Charting by Exception

￮ Document only deviations from pre-established norms.

￮ 3 components: Flow sheet, Reference Documentation, Bedside accessibility

￮ Computerized Documentation

￮ Facilitate speed in communication, accuracy in information, availability of


information, storage, data retrieval and data revision

￮ Point-of-Care-Charting: Allows immediate access to client information through


hand-held portable computer

REMEMBER! “What is not written is not done.”

Batch2023/tfn/1stsem/sy2019_2020/rlp

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