NURSING DOCUMENTATION

Siluh Nyoman Alit Nuryani, BoN, MN

OVERVIEW
Overview

of Nursing Documentation
Vocabulary related
Useful Conversation
Grammar Preference
Learning Task

WHY NURSING DOCUMENTATION

IMPORTANT..
Record keeping is an integral part of nursing and
midwifery practice. It is a tool of professional
practice and one that should help the care
process. It is not separate from this process
and it is not an optional extra to be fitted in if
circumstances allow.
(Nursing & Midwifery Council April 2002)

THE EXPECTATION OF A REGISTERED

NURSE IN THE FUTURE

The quality of your record keeping is a

reflection of the standard of your professional
practice.

Good record keeping is a mark of a skilled and

safe practitioner

Promote patient safety

WHO READ NURSING NOTES?

Nurses
Doctors
Medical and Nursing students
Dieticians
Physiotherapists
Other healthcare co-workers

AFFECTING EVERYBODY IN A TEAM!!!!

NURSING DOCUMENTATION
PROMOTES

High standards of clinical care

Continuity of care
Better communication & dissemination of
information between members of the MDT
An accurate account of treatment, care planning and
delivery of care
The ability to detect problems at an early stage
That you have taken all reasonable steps to care for
the patient and any action or omission on your part
have not compromised their safety
A record of arrangements you have made for the
continuing care for the patient
NMC 2002

LEGAL ISSUES
Nursing

records can be used in the

court
To review patient complaint
To review unexpected death
To review for visum et repertum

STANDARD NURSING DOCUMENTATION

Factual, consistent and accurate
Written as soon as possible after an event has
occurred, providing current information on the
care & condition of the patient
Written clearly in such a manner that the text
can not be erased
Written so that any alterations or additions are
dated, timed and signed in such a way that the
original entry can still be clearly read

NURSING DOCUMENTATION STANDARD

F.A.C.T.U.A.L
F = Focused on patient
A = Accurate
C = Complete
T = Timely
U = Understandable
A = Always Objective
L = Legible
(ANMC 2008)

NURSING PROCESS
Refer to a rationale
steps in a
systematic
approach to a
problem solving
assessment,
Diagnosis,
Planning,
Intervention,
and evaluation)

NURSING PROCESS
Assessment consists of :
Assessing Nursing/Illness History : Patients
identity, chief compliant, HPI(history prsent illness),
PNH (past Nursing History), Family history)
Obs, VS and general apppearance
Physical Examination
Result of Diagnostic test (urine, blood, X ray etc)

All of the above should be completed on

admission and reviewed on transfer.

THE FIVE ATTRIBUTES OF SYMPTOMS

P (Provokes) : including environmental factors
personal activities, emotional reactions, etc)
Q (quality ) : what is it like?
R (region) : Where is it? Does it radiate
S (severity ) : How bad is it?
T ( Time ) : When did it start, how long did it last,
how often did it come?

NURSING DIAGNOSIS
P = Problems of human responses (bio psychosocio-spiritual)
E = Etiology ( Pathophysiology, situation,
medication, maturation)
S = Signs and symptoms (result of interview,
observation, physical examination, and diagnostic
test

INTERVENTION: PLANNING AND

IMPLEMENTATION

Principles of planning should be SMART (Specific,

Measurable, Achievable, Reasonable, and time )

The client record contains daily documentation of

nursing activities
The plan of care is implemented

Competently

Caringly

Creatively

PLANNING
Nursing diagnosis

Goal Objective

Nursing Orders

Altered nutrition: less

than body
requirements related
to excessive vomiting
Symptoms are
vomiting three times,
.

Within 48-72 hours:

Eating portion =
until 1 portion each
meal

Monitor intake and

output daily

Body weight
increased - kg

Provide good oral

care
Create comfort
environment

Albumin normal
Verbalize important
adequate nutrition
(high calories and
protein)
Maintain present
weight

IMPLEMENTATION
Problem

Implementation

Evaluation

Altered Nutrition : less

than body
requirements

Creating comfortable
environment

Increasing her
appetite

Demonstrate to keep
oral hygiene

Eating portion each

meals, drink milk 200
cc twice a day

Teaching importance
nutrition for healthy
Increasing her
appetite with ask
favourite food

Albumin : 2.7
Anemis sign -

EVALUATION
SOAP
Altered nutrition: less than body requirements
related to nutrition intake
S= she said that she loss her appetite
O= weight : 22.5 kg, portion of eating
A = problem solved but still can happen again since
patient has severe infection
P= Teach patients family to support by providing
favorites meals

USEFUL CONVERSATION
How was your sleep last night?
Do you still feel painful on your surgery site?
Is there any pain in any part of your body?
How intense is the pain on scale of 0 to 10 (with 10
being the worst possible pain?)
Can you move your finger?
Do you still have nausea and vomiting
Do you feel pressure on your cast?
How was your urine output?
How was you bowel habits?

VOCABULARY RELATED
Antibiotic
Antifungal
Antivirus
Antidiuretik
Antidepressant
Antipyretic
Cough medicine
Chemotherapy
Radiotherapy
Hypoglicemia,
Hyperglicemia

Diet
Appetite
Dysphagia
Rash
Dryness
Constipation
Diarrhoea
Incontinence
Sleep/rest pattern
insomnia

VOCABULARY RELATED
Nutrition pattern
Mental status
Conscious/unconsciou
sness
Consent form
Discharge planning
Falls risk assessment
Refusal of treatment
Past medical history
Medication

Alert
Joundice
Dyspnea
Constipation
Cyanosis
Anorexia
Inflamation
Respiration
edema

CONT.
Infection
Nosocomial infection
Virus
Viral infection
Contaminated food or drink
Feces/urine
Fever
Diarrhea
HIV/AIDS
TB/tuberculosis

CONT.
Injury
Sprain
Dislocation
Fracture
Rupture
Swelling
Pain
Cast
Capilary refill

GRAMMAR FOCUS : PREFERENCE

Kelebihsukaan thd suatu benda/kegiatan

S + Like + Noun/Gerund + Better Than +

Noun/gerund
Example
Mr John like walking better than swimming

S + Prefer +Noun/Gerund + to + Noun/Gerund

Example
Peter prefer eating porridge to eating steam rice

CONT.

S + prefer + to Infinitive + rather than +

infinitive/gerund/noun
Example
Christy prefer to go to Australia rather than to
England

S + would prefer + to infinitive + (rather) than +

infinitive/gerund/noun
Example
Lina would prefer to meet orthopedics rather than
meeting general surgeon

CONT.

S + would rather + infinitive + than +

infinitive/gerund/noun
Example :
Tony would rather take oral medications than
injection

CONT.

Implied causative

S + Prefer + Someone (subject)+ to Infinitive

Example
Doctor prefer this patient to take oral medication

S + would rather + someone + To infinitive + verb

Example
I would rather this patient to go to operating
theatre immediately

CONT.

Comparison of Equality
As + Adjective + as

Example :
Please take a deep breath as deep as you can!
Squeeze my hands as strong as you can

CASE STUDY

A 45 year old male, complaining severe cough, and

difficult to breath for 3 months. He had been taken
medicine from drug store but he hasnt recovery
from his illness. He works as driver and live in poor
family. His father had Tuberculosis , no allergies to
medicine. Thoraks : TB

Please fill out assessment form and make nursing

care plans and evaluation using SOAP based upon
this case