Nursing documentation ppt

Documentation is a act of recording client status and care in written form.

1. FON ASSIGNMENT TOPIC-DOCUMENTATION IN NURSING

2. GENERAL OBJECTIVE Define documentation Enlist Purpose of documentation Types of documentation Explain Documentation System Do And Don’t Discuss Forms Of Documentation Nurse’s Responsibilities In Documentation

3. Definition Documentation-Documentation is the act of recording client’s status and care in a written form. Doucmentation is any printed or written record of activities.

4. Purpose Of Documentation Communication Education Legal Document Quality Assurance Research Nursing Audit Health Care Analysis

5. Types Of Documentation Recording Charting Recording- Is a brief account of the personal history, medical history, results of diagnostic tests, findings in physical examination, treatment and nursing care, Progress notes and condition on discharge.

6. Charting- Is a permanemt , written and complete record of the health history and sociological information obtained from a person admitted to a hospital by listening to him, looking at him and treating him.

7. Documentation System Source-Oriented Record. Problem-Oriented Medical Record (POMR). Problem, Itervention , Evaluation (PIE). Focus Charting. Charting by exception (CBE). Computerized documentation and care management.

8. Source-Oriented record- Source-oriented is a narrative Recording by each member of the health care team on separate documents. Problem-oriented Medical Record- (POMR) are organized around the client’s problem. It employs a structured, logical format, Which focuses on the client’s problem.

9. Problem, Intervention, Evaluation- PIE is an acronym for problems,intervention and evaluation of nursing care this system was to develop streamline documentation. Focus Charting- highlights the client’s concerns, problems or strengths. Is a documentation System using column to format data.

10. Charting by exception (CBE)- Is a documentation in which only abnormal or significant finding or exceptions to norms are recorded. CBE uses pre-printed flow sheets to document the most aspects of care. Computerized documentation- Computers make care planning and Documentation relatively easy. Nurses use computers to store the client database, add progress.

11. Do’s and Do Not’s Do’s Use objective, specific and factual description Correct the charting errors Chart all teaching Review your notes Do support medical necessity

12. Do Not's Leave blank space for a colleague to chart later Chart in advance of the event Use vague terms Chart for someone else Use patient or client as it is in the chart Alter a record, even if requested by a physician Record assumption or a word reflecting bias

13. Forms Of Documentation Kardexes- Is a concise method of organizing and recording data about a client, making information quickly accessible to all health professional. It contains- Client information, list of medical diagnosis on priority, allergies, list of daily treatments, procedures and measurement of vital signs, procedure order Such as X-ray and lab tests.

14. Flow Sheets- A simple form that gathers all important data regarding a patient’s condition it includes graphic records, medication administration record, etc. Progress Notes- Is the notes made by nurses provided information about the progress a client is making towards Achieving desired outcome.

15. Discharge Summary- Is completed when the patient is being discharged and refered to home. It includes: Client instructions about medication, diet, food-drug Interaction, etc.

16. Nurse’s Responsibilities In Documentation Should keep under safe custody of nurses. No individual sheet should be separated. Not accessible to patients and visitors. Strangers is not permitted to read records. Errors in nursing charting must be corrected Promptely in a manner that leaves no doubts About the facts.

17. Summary Today we have discussed about Types of documentation System of documentation Do and Do not’s Forms of documentation Nurse‘s responsibilities in documentation

18. Conclusion Documentation is the act of recording client’s status and care in the written form. Client records are legal documents that provide evidence of a client’s Care. Examples of documentation system include PIE, focus charting, charting by exception (CBE), computerized documentation and case management.

19. Questions Define documentation. Enlist the purposes of Documentation. What are the types of documentation? Explain uses of documentation systems. What are the nurse’s responsibilities in documentation

20. Reference Nursing Foundation Jaypee. Author- BT basavanthappa Nursing Foundation- 3 rd edition Author- I Clement Jems.com