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ACN
Objectives
Define
nursing documentation (ND) Purpose of ND Advantage of nursing documentation Principle of ND Example of inaccurate & accurate ND Different record keeping documents. Consequences of inaccurate ND
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Nursing Documentation
Any written or electronically generated information about a client that describes the care or service provided to that client.
Accurate record keeping and careful documentation is an essential part of nursing practice.
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Nursing documentation clearly describes: An assessment of the clients health status, nursing interventions carried out, and the impact of these interventions on client outcomes; Information reported to a physician or other health care provider.
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To facilitate communication To promote good nursing care To meet professional and legal standards Satisfaction of Legal and Practice standards Education Research Reimbursement
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Cont
Accurate, timely documentation reflects care provided: Professional, legislative, & agency standards Enhance nursing care Facilitate communication b/w nurses & other health care providers.
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Cont
It also reflects the application of : Nursing knowledge Nursing skills & judgment Established accountability Conveys the unique contribution of the nursing to health care
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Use of Common Vocabulary Use of common vocabulary improve intrateam communication and lessen the chance of misunderstandings. Legibility Writings must be easily readable, without any chance of error. Abbreviations and Symbols Use only authorized abbreviations and symbols.
Organization Start every entry step by step with the date and time. Chart in a chronological order Accuracy Use factual, descriptive terms to chart exactly what was observed or done. Use correct spelling and grammar, and write complete sentences.
Documenting a an Error Facilities require nurses to report errors on incident reports, Document the error in the nurses notes Confidentiality Nurses are bound by ethical codes and laws to treat all client information in a confidential and professional manner. The client records should not be with unconcerned personnel
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Inaccurate Example
Mr. X received from morning staff in well condition. Well oriented, eating well. Vital signs checked & recorded. Physician checked the pt, no any further order. Continue same RX.
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Accurate Example
Mr. X. received from Night shift. Oriented to time, place & person. Breathing spontaneously on room air, RR=20/m. B.P 110/ 70mmgh, pulse=80/m. chest tube in placed with bubbling & column movement present. catheter in placed urine output 30ml/hr, stool passed normally. IV fluids 100ml / hr continue for 24 hrs.________ A.Razzak.
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history (HX) Graphic or flow sheet Medication administration record Nursing KARDEX Standardized care plans Discharge summary
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Methods of Documentation
Narrative
Focus
Narrative Charting
Source-Oriented Charting
Problem-Oriented Charting
PIE Charting
Focus Charting
Charting by Exception
Decreased documentation time. Increased legibility and accuracy. Clear, decisive, and concise words.
Statistical analysis of data. Enhanced implementation of the nursing process. Enhanced decision making. Multidisciplinary networking.
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Refrences
DUGas,
(1999). Nursing Foundation: A Canadian Perspective. Scarborough: Prentice Hall Canada, P. 480
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