Principles of Documentation

documentation charting nursing principles

1. PRINCIPLES OF PRINCIPLES OF
DOCUMENTATIONDOCUMENTATION
Ms. JEENA AEJY Ms. JEENA AEJY

2. DOCUMENTATION MUST BE DOCUMENTATION MUST BE
CONSISTENT WITH CONSISTENT WITH
PROFESSIONAL AND AGENCY PROFESSIONAL AND AGENCY
STANDERDS, COMPLETE, STANDERDS, COMPLETE,
ACCURATE , CONCISE, ACCURATE , CONCISE,
FACUAL, ORGANIZED AND FACUAL, ORGANIZED AND
TIMELY, LENGTHY, PRUDENT TIMELY, LENGTHY, PRUDENT
AND CONFIDENTIAL.AND CONFIDENTIAL.

3. 1. DATE & TIME1. DATE & TIME
Document date and time of Document date and time of eacheach recording. recording.
Record time in conventional manner(Eg. Record time in conventional manner(Eg.
9am, 6pm etc)9am, 6pm etc) or according to the 24 hour or according to the 24 hour
clock(military clock)clock(military clock)
Avoid recording in advance.Avoid recording in advance.

4. 2.LEGIBILITY2.LEGIBILITY
Entries must be legible Entries must be legible
and easy to read.and easy to read.
Writing must be clear.Writing must be clear.
Very important in Very important in
recording numbers and recording numbers and
medical terms.medical terms.

5. 3.CORRECT SPELLING3.CORRECT SPELLING
Correct spelling is essential for accuracy.Correct spelling is essential for accuracy.
If unsure about the spelling use a dictionary If unsure about the spelling use a dictionary
or other resource book.or other resource book.

6. 4.PERMANANCE4.PERMANANCE
Entries should be Entries should be
done in dark ink. done in dark ink.
It helps to identify It helps to identify
changes and changes and
allows allows
duplication duplication
(Xerox).(Xerox).

7. 5.ACCEPTED TERMINOLOGY5.ACCEPTED TERMINOLOGY
Use commonly accepted abbreviations, Use commonly accepted abbreviations,
symbols and terms that are specified by the symbols and terms that are specified by the
agencyagency
Use universally accepted abbreviations.Use universally accepted abbreviations.

8. 6.FACTUAL6.FACTUAL
Descriptive objective information about Descriptive objective information about
what nurse sees, hears, feels and smells.what nurse sees, hears, feels and smells.
Use of inference without supporting data is Use of inference without supporting data is
not acceptable.not acceptable.
Vague terms like appears, seems or Vague terms like appears, seems or
apparently is not accepted. apparently is not accepted.
Include objective signs of problems.Include objective signs of problems.
Subjective data is documented in client’s Subjective data is documented in client’s
exact words within quotation marks.exact words within quotation marks.

9. 7. ACCURATE7. ACCURATE
Use of exact measurement establishes accuracy.Use of exact measurement establishes accuracy.
Eg. Intake 450ml of water than writing Eg. Intake 450ml of water than writing
adequate amount of water.adequate amount of water.
Clients name and identifying information is Clients name and identifying information is
written on each page.written on each page.
Before making any entry in the chart make sure Before making any entry in the chart make sure
that it is correct.that it is correct.
Chart only your observations and actions to be Chart only your observations and actions to be
accountable.accountable.

10. If any mistakes occur while recording, If any mistakes occur while recording,
draw a line through it and write above or draw a line through it and write above or
next to original entry with your initials or next to original entry with your initials or
name.name.
Do not erase, blot or use correction fluids.Do not erase, blot or use correction fluids.
Follow agencies policy while making Follow agencies policy while making
computerized charting.computerized charting.
Write on every line but not in between the Write on every line but not in between the
lines.lines.
Draw a line through the blank spaces so that Draw a line through the blank spaces so that
no additional information can be added.no additional information can be added.

11. 8.SEQUENCE8.SEQUENCE
Document events in order of occurrence.Document events in order of occurrence.
Eg. Record assessments, then nsg Eg. Record assessments, then nsg
interventions and then the client responses.interventions and then the client responses.
Update or delete problems as needed.Update or delete problems as needed.

12. 9. APPROPRIATENESS9. APPROPRIATENESS
Record informations pertaining to the Record informations pertaining to the
client health problems& care only.client health problems& care only.
Avoid personal informations that are in Avoid personal informations that are in
appropriate.appropriate.

13. 10. COMPLETENESS10. COMPLETENESS
Document all necessary informationsDocument all necessary informations
It should give a clear picture of what took place.It should give a clear picture of what took place.
Complete pertinent assessment data such as Complete pertinent assessment data such as
vital signs, wound drainage, client complaints, vital signs, wound drainage, client complaints,
who was notified and what interventions are who was notified and what interventions are
carrid out etc are recorded.carrid out etc are recorded.

14. The following informations should be included The following informations should be included
in the chart:in the chart:
A new or changed informationA new or changed information
Signs and symptomsSigns and symptoms
Client behaviorClient behavior
Nursing interventionsNursing interventions
MedicationsMedications
Physician’s orders carried outPhysician’s orders carried out
Client teachingClient teaching
Client responseClient response

15. 11.CURRENT11.CURRENT
Timely entries are mustTimely entries are must
Keeping record at bed side may Keeping record at bed side may
facilitate immediate facilitate immediate
documentationdocumentation

16. Activities/findings recorded at the time of Activities/findings recorded at the time of
occurrence include the followingoccurrence include the following
Vital signsVital signs
Administration of drugs or RxAdministration of drugs or Rx
Preparations for diagnostic tests or surgeryPreparations for diagnostic tests or surgery
Change in the clients health status & who Change in the clients health status & who
was notified.was notified.
Admission, transfer, discharge or death of a Admission, transfer, discharge or death of a
client.client.
Treatement for a sudden change in client’s Treatement for a sudden change in client’s
status.status.

17. 12. CONCISENESS (BRIEVITY)12. CONCISENESS (BRIEVITY)
Recording need to be brief as well as complete Recording need to be brief as well as complete
to save time in communication.to save time in communication.
Client’s name and the word client can be Client’s name and the word client can be
omittedomitted
Eg. “perspiring profusely. Respiration shallow. Eg. “perspiring profusely. Respiration shallow.
28/mt”28/mt”
Use accepte abbreviationsUse accepte abbreviations

18. 13. ORGANIZED13. ORGANIZED
Information should have logical mannerInformation should have logical manner
Eg. description of pain, nurses assessment and Eg. description of pain, nurses assessment and
interventions and the client response.interventions and the client response.
This helps in preventing any omission of This helps in preventing any omission of
informations.informations.
Easy to read.Easy to read.

19. 14. SIGNATURE14. SIGNATURE
Each recording is signed by the nurse.Each recording is signed by the nurse.
Signature includes the name and the title Signature includes the name and the title
In computerized charting nurse will have his or In computerized charting nurse will have his or
her own code.her own code.

20. 15.CONFIDENTIALITY15.CONFIDENTIALITY
All the client’s record are confidential filesAll the client’s record are confidential files
The information in the chart is personal as The information in the chart is personal as
well as legal.well as legal.
Record shouldn't be copied without the Record shouldn't be copied without the
permission of the client.permission of the client.
Nurse should not allow any outsiders to Nurse should not allow any outsiders to
verify the client record.verify the client record.

21. Thank youThank you