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BASIC DOCUMENTS IN NURSING

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 OUTLINE

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 Introduction.

 Why documentation?

 Key documents In Nursing.

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 INTRODUCTION

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 ‘If it was not documented, it never happened’, so goes the
old adage.

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 WHY DOCUMENT?

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 Accountability; for reward or sanction.
 As evidence of action taken.

 Continuity of care.

 Monitoring and Evaluation.

 Legal purposes.

 Research.

 More......................

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 KEY DOCUMENTS IN NURSING
 Admission and Discharge Register.

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 Care Index (Cardex).
 Nursing Care Plan.
 Various Charts (vital signs, fluid, partograph etc.).
 Treatment Sheet.
 Drug Register.
 Patient transfer notes.
 Shift Report

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 ADMISSION AND DISCHARGE REGISTER
 Personal data for newly arrived patients in the ward are entered.
This includes-:
 Name, age, sex, address/tel. number. etc
 DOA, in patient number
 Residence, next of kin.
 Diagnosis.
 Column on ‘Discharge’ filled when patient goes home, is
transferred or dies.

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 CARE INDEX (CARDEX)
 Contains vital information on newly arrived patients, care &
treatment till discharge, transfer or death.
 The information include but not limited to-:

 Assessment ;Detailed history (history of present illness, past

health history, family & socio-economic history etc).
 Interventions & patient’s response to them, recorded
immediately they occur with dates and clear timelines.
 Name and signature of the person executing care.

 Info forms basis for evaluation of care outcomes.

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 NURSING CARE PLAN
 Problem solving tool.
 Set of prioritized interventions developed to address
identified health problem/s.
 Done in systematic and cyclic manner from assessment,
nursing diagnosis, planning, implementation, evaluation
and documentation.

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 Feb 12, 2024
OBSERVATION CHARTS

 Specific tools designed for documentation of vital signs

made from patients.
 Made for assessment and monitoring progress of care and
treatment.
 Frequency of monitoring specific to the vital sign or/and
condition of patient.
 Some are universal while others are tailor-made for
specific situation.
 Examples of charts????
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 FLUID CHART

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 Dehydration is one of the most common conditions that
nurses deal with especially in OPD,A&E and wards.
 Some conditions require patients to feed on fluid diet
either orally, intravenously etc.
 Some patients may be having excessive or inadequate
fluid output.

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 FLUID CHART CONT…

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 Nurses must monitor fluid intake/output and record in
appropriate column of fluid chart.
 The info helps to calculate and correct fluid & electrolyte
imbalance.
 Final balancing done at the end of 24hours or as frequently
as patients condition may dictate.
 Helps determine ratio between fluid intake & output.

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 TREATMENT SHEET

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 Communication tool linking nurses with doctors, clinical
officers and other care providers.
 Contains drugs prescribed by doctors and clinical officer.

 Nurse MUST determine accuracy of prescription before

drug administration.
 Nurse must indicate date and time of commencement of
treatment.

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 DRUG REGISTER

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 Nurses keep records of drugs received from pharmacy
and kept in the ward/unit to be administered to the
patients.
 Three types of registers-:

 Oral antibiotics.

 Injectable antibiotics.

 Dangerous drugs.

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 PATIENT TRANSFER NOTE
Purpose is to facilitate continum of care from one care

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
delivery point to another.
 Written by the nurse and indicates Nursing diagnosis,
nursing care so far given at time of transfer and anticipated
care to be continued at the next point.
 Nurse carries this and hands it over with patient to the
nurse at the point of referral.

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 DAILY BED RETURN

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 Shows the following-:
 Ward’s bed capacity.

 Names, number of admissions and discharges within the

last 24hrs.
 Entry made by the nurse doing transaction.

 Must be well balanced daily by the ward Manager before

being submitted to records Department.

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 SHIFT REPORT

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 Previously known as Matron’s report.
 Written by covering nurse supervising shift at either
6.00pm or 6.00am.
 Captures major/unique incidences during day and night
-:
 Acutely ill patients

 Patients who need special attention

 Sick hospital staff etc.

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 COMMODITY REGISTER

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 Newly introduced to improve supply and availability of
basic medical commodities necessary for high quality
care.

 Maintained by nursing officer in charge of commodity

management.

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 THE END

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THANK YOU

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