Professional Practice I

Documentation
Power Point #1 1
 What is Documentation?

 “thewritten, legal record of all

interactions with a patient”

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CNO Practice Standard
Documentation

Purpose of documentation is:

 communication
 accountability
 legislative requirement
 quality improvement
 research
 funding and resource management

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In general…

 effective communication is essential for

coordination and continuity of care
 communication in health care includes
documenting, reporting and conferring
 will use all three of these on a regular
basis
 many, many legalities involved in all of
these processes

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 data has many uses
 each agency has specific guidelines on
type/format of documentation
 good documentation is your best
defense if you’re accused of negligence
 permanent legal document that details
what you did with and for the pt
 errors and omissions can affect pt care,
undermine your credibility and cause
legal problems
 you can never document too much!!!!
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CNO Documentation
Guidelines

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Complete

 clear

 concise

 complete

 relevant

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Accurate

 exact

 abbreviations

 errors

 never alter another person’s charting

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Factual

 descriptive, objective account

“hear” “see” “feel” “smell”

 avoid judgments/labels
“confused” “agitated” “difficult”

 avoid meaningless words

“appears” “seems” “good” “usual day”9
Current/Timely

 as close to the event as possible

 NEVER BEFORE

 no “block charting”

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 Date & Time
 beginning of each entry
 24 hour clock

Signature & Designation

 end of each entry
 end of each page
 1st initial & last name
 SPN1

Permanent Ink
Legible
No spaces 11
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 Organized

chronological order

late entries

10/11/20 LE @ 1000 pt. c/o fatigue. Assisted back to bed

1400 A1. Minimal assistance required. Denies being
lightheaded. Steady on feet.
------------------------------------------- P. Munro-Gilbert
RN ---------------------------

Logical order
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Documentation and the Nursing Process:
Assessment/Diagnosis/Plan/
Implementation/Evaluation

“subjective” data
objective data
nursing care
Tx
Dx tests
teaching
visits
reporting

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And a few more “rules”…

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Document only for yourself

Co-signing Entries

Know Agency Policies

 expectations
 type of charting
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What to chart?

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Points to Ponder...
 only sign what you have actually done
 never chart for someone else
 sign all entries with designation
 put line through unused lines
 never “white out” anything in a chart
 never tamper with medical records
 don’t criticize other health professionals in the
chart

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 document any comments that a patient or
family member make about a potential lawsuit
against the health care agency or personnel
 eliminate bias from written descriptions of the
pt

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