Nursing Documentation Quiz

Documentation & Reporting

• Nursing documentation is an integral part of registered nurse practice, not optional.
• It's used to ensure high-quality patient care.
• Documentation includes any written or electronically-generated information about a client describing the care/service provided.
• Clients include individuals, families, groups, populations or entire communities needing nursing expertise.
• Documentation clearly describes the patient's health status, nursing interventions, their impact on patient outcomes, and information reported to other health-care providers.
• Purposes of documentation include communication, legal documentation, research, statistics, and education.
• Quality assurance, planning client care, and reimbursement are also purposes of documentation.

Benefits of Nursing Documentation

• Creates an account of judgment
• Reflects accurate, timely care provided
• Incorporates nursing knowledge
• Demonstrates nursing skills and judgment
• Shows established accountability
• Reinforces the nursing contribution to healthcare

Documentation Principles

• Good documentation is factual
• Accurate
• Complete
• Timely
• Concise
• Legible

Factual Documentation

• Objective information about observed, heard, felt, smelled, or thought.
• Avoiding inferential statements without basis
• Avoiding vague or apparently ambiguous terminology
• Using client's exact subjective words in quotation marks

Accurate Documentation

• Using exact measurements (e.g., 450 ml of water instead of "adequate amount").
• Clear client identification on each page
• Ensuring correctness before charting
• Charting only observations and actions to maintain accountability

Complete Documentation

• Recording all necessary information
• Creating a clear picture of events
• Documenting vital signs, drainage, client complaints, notifications, and interventions
• Note any condition changes
• Documenting patient responses (especially unusual, undesired, or ineffective responses) and communication with the patient's family.

Timely Documentation

• Documenting the date and time of each recording.
• Using conventional time formats (e.g., 9:00 am or 6:00 pm) or 24-hour clock.
• Avoiding recording information in advance (illegal).

Concise Documentation

• Brief but comprehensive
• Omitting unnecessary words like "client"

Legible Documentation

• Using black ink for clarity
• Drawing a line through mistakes and noting the correction above or beside the original, along with initials.

When to Document

• Patient's initial admission
• Daily documentation of care
• After providing nursing care
• When there's a change in patient condition
• During emergency situations
• At patient discharge

Initial Admission Assessment

• Documenting the time of admission or transfer
• Listing patient complaints
• Recording vital signs, height, weight, and allergies
• Providing a general observation of the patient

Daily Documentation

• Recording shift time and date of observation along with care given
• Noting patient condition at return from procedures or recovery
• Describing dressings (if dry or wet)
• Charting drainage, fluids specifics, and insertion site condition
• Charting medication according to the five rights

Documenting Nursing Care

• Documenting the exact time of procedures, patient condition post-procedure, vital signs, and patient education/instructions (e.g., NPO, X-ray)
• Recording specific care given
• Noting patient complaints and nursing interventions
• Describing pain complaints and characteristics
• Recording notifications to the doctor and prescribed medications
• Documenting effects of analgesics

Documenting Changes in Patient Condition

• Recording any significant changes in patient condition
• Recording physician visits
• Documenting medication refusal, including the notification to the physician on duty

On Discharge Documentation

• Documenting the patient's general condition at discharge time/date
• Noting discharge instructions for medications, diet, dressing, and referrals to clinics
• Recording information on significant others accompanying the patient

Do Not Document

• Inappropriate abbreviations
• Routine tasks (e.g., bed making)
• Omitting signature after charting progress notes

Methods (Styles or Formats) of Nursing Documentation

• Narrative Documentation- Traditional, descriptive
• Problem-Oriented Medical Record (POMR)- Problem-solving format
• Subjective, Objective, Assessment, Plan (SOAP)- Structured, comprehensive format
• Assessment, Plan, Intervention, Evaluation (APIE)- Comprehensive format
• Focus Charting (DAR)- Data, action, response format
• Problems, Intervention, Evaluation (PIE)- Organised by problem

Reporting

• Reporting happens when individuals share client care information; face-to-face or by phone.
• Verbal Reporting: Essential, accurate, succinct summary highlighting recent changes. Avoiding judgments. Providing client name, room number, bed number, reason for admission, and test/therapy results for the last 24 hours.
• Telephone Reporting: Identifying oneself and the location, natural tone, clear and precise information (verified), recording information with a signature, respecting confidentiality. Reporting when a call was made, who was called/reporting, who the information was given to, what information was given, and what was received.

Legal Documentation

• Charts are legal documents available to staff, patients, and lawyers.
• Written consent needed for invasive procedures, diagnostic procedures, experimental/chemotherapeutic medication.
• Documentation of leaving against medical advice (AMA).

Administrative Documentation

• Routine paperwork for admission or transfer
• Birth and death certificates; insurance forms.