NURSING

DOUCUMENTATION
Objectives :

• Definition
• Purpose of Documentation
• General guidelines for documentation
 NURSING DOUCUMENTATION

A written record of data, information which the nurse writes

about the patient to communicate with other members of

health team who are involved in the patient care.

PURPOSES OF DOCUMENTATION
1- COMMUNICATION

The record serves as the vehicle by which different health

professionals who interact with a client communicate with each other.
This prevent fragmentation, repetition and delays in client care.
2- PLANNING CLIENT CARE

Nurses uses data from the client’s record to plan care for
that client. Nurses use baseline and on-going data to
evaluate the effectiveness of the nursing care plan.
3- QUALITY MANAGEMENT/AUDITING

An audit is a review of client records to determine if

particular health agency is meeting a particular standards
4- RESEARCH

The information contained in a record can be

a valuable source of data for research.
5- EDUCATION

A record can frequently provide a

comprehensive view of the client, the illness
effective strategies and factors that affect the
outcome of the illness.
 LEGAL PURPOSE

The client’s record is a legal documentation and

is usually admissible in court as evidence. It
serves as a legal document of the client’s health
status and care received.
GENERAL GUIDELINES FOR
DOCUMENTATION
• DATE AND TIME
• Record the time according to the 24 hour clock (military clock), which
avoids confusion about whether a time was AM or PM
• Timing :No recording should be done before providing nursing care.
• When the client status changes, document immediately.
• Accepted terminology :Example- D/C may mean discharge or discontinue.
• LEGIBILITY :All entries must be legible and easy to read.
• CORRECT SPELLING
 SIGNATURE

Each recording on the nursing notes is signed by the

nurse making it. The signature includes complete name
or initial of first name followed with family name.

Example : Amerah- alasiri

 MISTAKEN ENTRY

When recording a mistake is made, draw a line through

it and write the words mistaken entry above or next to
the original entry, with your name. Do not erase, blot
out or use correction fluid. The original entry must
remain visible.
 Accuracy
Example :
Write the client “refused
medication” (fact) than to
write
that the client “was
uncooperative” (opinion).
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