Nursing Documentation: Nursing Documentation Examples
It is a fact that accurate record keeping and careful documentation is an essential part of nursing practice and effective communication among nurses vital to the quality of client care. Generally nurses communicate with their
colleagues, clients and other healthcare professionals through discussion, reports and records.
A discussion is an informal oral discussion of subject by two or more nurses or other healthcare
personnel to identify a problem or establishes strategies to resolve a problem.
A report is an oral, written or computer-based communication intended to convey information to others. For instance, nurse report on client’s progress at the end of a work shift during handing over.
A record is a written or computer –based communication intended to convey information to others. The process of making an entry on a client record is called recording, charting or documenting.
A clinical record, also called a chart. Client record is a formal, legal document that provides evidence of client care.
The procedure for documentation may vary from institution to institution, but the principle involved are generally the same. The history of documentation and record keeping in nursing emanated from Florence Nightingale who, during her time, documented all she saw and did. Nurses are responsible for accurate, complete and timely documentation and reporting. As an instrument of continuous client care and as legal document, the client record should contain all pertinent assessment, planning, intervention and evaluation for the client. Documentation and reporting of the client’s condition require adherence to the highest standards of confidentiality. After actions have been performed on a client, they should be documented.
If a nurse performs her duty in error, and without documentation, she is accountable to the client who received the care; the doctor who prescribed the treatment, the nursing service that sets the standard of expected performance, the institution in which nursing services is practiced and the society that demands professional excellence. When nurses perform care, they must be accountable for their action as documentation connotes accountability.
All members of a healthcare team share information through documentation and reporting. Documenting client’s records is important for the following reasons:
1. Serves as a vehicle by which different health professionals who interact with a client communicate with each other. This prevents fragmentation, repetition, and delays in client care.
2. Ensure continuity of patient care for future management.
3. Provides evidence for evaluation purposes. For instance, nurse use baseline and ongoing data to evaluate the effectiveness of the nursing care plan. In addition, records and reports assist nurse managers to evaluate staff performance.
4. Serves as an audit tool. Client’s records may be reviewed to determine if a particular health institution is meeting its stated standards.
5. Serves as an educational tool for nursing students. The information contained in a record can be a valuable source of data nursing research.
6. Investigations into complaints about care will look at and use the patient/client documents and records as evidence, so high quality record keeping is essential. The hospital or care home, the NMC, a court of law or the Health Service Commissioner may investigate the complaint, so it makes sense to get the records right. A court of
law will tend to assume that if care has not been recorded then it has not been given.
7. A client’s record is a legal document and is admissible in court as evidence.
8. Aid hospital management in planning. Information from record may assist healthcare planner to identified institutional needs, such as over utilized and underutilized hospital services. They can often establish from record the cost benefit and cost effectiveness of various services and identify those services that cost the hospital money and those that generate revenue.
GUIDELINES FOR DOCUMENTATION AND RECORD KEEPING
The basic guidelines for good practice in documentation and record keeping apply equally to written records and to computer- held records.
The Nursing and Midwifery Council (NMC 2002) has said that patient and client records should:
– Be based on fact, correct and consistent.
– Be written as soon as possible after an event has happened to provide current (up to date) information about the care and condition of the patient or client.
– Be written clearly and in such a way that the text cannot be erased’ (rubbed out or obliterated).
– Be written in such a way that any alterations or additions are dated, timed and signed, so that the original entry is still clear.
– Be accurately dated, timed and signed.
– Not include abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subjective statements’.
– Be readable on any photocopies’.
– Be written, wherever possible, with the involvement of the patient,.
– Be written in terms that the patient or client can understand’.
– Be consecutive’ (uninterrupted).
– Identify problems that have arisen and the action taken to rectify’ (correct or put right).
– Provide clear evidence of the care planned, the decisions made, the care delivered and the information shared’.
Documentation and record keeping are vital instruments in the management of nursing services, since the client record may be used to provide evidence in court. Nurses must not only maintain confidentiality of the client’s record but also meet legal standard in the process of documentation.
Aside from client’s record, ward, unit and departmental meetings should be documented as evidence for important decisions taken. The manager should equally keep records of ward rosters, protocol of care, policies and procedures
as they help to clarify actions. Inventory record of equipment, material supplies made to the ward should be kept and monitored. This enables the manager to keep track of supplies. In summary, documentation is a skill to be
acquired by all nurses. A ward manager should be highly educated, intelligent, competent, and assertive. For effective ward management, he/she should combine his/her professional as well as managerial roles in the performance of his/her duties.
By Ali Muhammad Goniri RN, RM, DNE, BNSC, PGDE
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