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Documentation & Reporting in Nursing

Documentation is anything written or printed that is relied on as a proceedings of examination for verified men-folks. Documentation and declarationing in nursing are wanted for uninterruptedness of trouble it is as-well a juridical capacity showing the nursing trouble effected or not effected by a nurse.


  1. Communication
  2. Planning Client Care
  3. Auditing Bloom Agencies
  4. Research
  5. Education
  6. Reimbursement
  7. Legal Documentation
  8. Health Trouble Analysis

Documentation Systems

1. Source – Oriented Record

  1. The transmitted client proceedings
  2. Each idiosyncratic or division reachs notations in a disconnected exception or exceptions of the client’s chart
  3. It is suitable accordingly trouble furnishrs from each instruction can abundantly establish the forms on which to proceedings grounds and it is comfortable to investigate the knowledge
    • Example: the advents division has an advent prevarication; the physician has a physician’s appoint prevarication, a physician’s fact prevarication & speed notes
  4. NARRATIVE CHARTING is a transmitted sever of the beginning-oriented proceedings

2. Problem – Oriented Medical Proceedings (POMR)

  1. Established by Lawrence Weed
  2. The grounds are compact according to the completions the client has rather than the beginning of the knowledge.
The indelicate (4) basic components:
  1. Database – consists of all knowledge unconcealed environing the client when the client primitive enters the bloom trouble production. It embodys the nursing toll, the physician’s fact, gregarious & race grounds
  2. Problem List – extraneous from the groundsbase. Usually kept at the face of the chart & serves as an protest to the numbered entries in the speed notes. Problems are registered in the appoint in which they are verified &    the register is persistently updated as new completions are verified & others resolved
  3. Plan of Care – trouble delineations are generated by the idiosyncratic who registers the completions. Physician’s transcribe physician’s appoints or medical trouble delineations; protects transcribe nursing appoints or nursing trouble delineations
  4. Progress Notes – chart proceedings made by all bloom professionals implicated in a client’s trouble; they all use the similar character of prevarication for notes. Numbered to agree to the completions on the completion register and may be lettered for the character of grounds
Example: SOAP Format or SOAPIE and SOAPIER S – Subjective grounds O – Concrete grounds A – Assessment P – Plan I – Intervention E – Evaluation R– Revision
  • It encourages collaboration
  • Problem register in the face of the chart alerts troublegivers to the client’s wants & reachs it easier to trail the foundation of each completion.
Disadvantages of POMR:
  • Caregivers contend in their ability to use the required charting format
  • Takes invariable sleeplessness to suppress an up-to-end completion register
  • Somewhat flimsy accordingly tolls & interventions that employ to over than one completion must be continual.

3. PIE (Problems, Interventions, and Evaluation)

  • Groups knowledge in to three (3) categories
  • This regularity consists of a client trouble toll floe prevarication & speed notes
  • FLOW SHEET – uses unfair toll criteria in a severicular format, such as ethnical wants or authoritative bloom patterns
  • Eliminate the transmitted trouble delineation & conglutinate an ongoing trouble delineation into the speed notes

4. Focus Charting

a. Intended to reach the client & client concerns & strengths the nucleus of trouble b. Three (3) columns for proceedingsing are usually used: end & span, nucleus & speed notes

5. Charting by Exception

  • Documentation regularity in which simply exceptional or speaking findings or exceptions to norms are proceedingsed
  • Incorporates three (3) key elements:
    • Flow prevarications
    • Standards of nursing trouble
    • Bedside path to chart forms

6. Computerized Documentation

  • Developed as a way to direct the colossal magnitude of knowledge required in synchronous bloom trouble
  • Nurses use computers to accumulation the client’s groundsbase, add new grounds, imagine & amend trouble delineations & instrument client speed.

7. Case Management

  • Emphasizes attribute, cost-effective trouble delivered among an orderly protraction of stay
  • Uses a multidisciplinary vestibule to delineationning & instrumenting client trouble, using censorious pathways.

Nursing Trouble Delineation (NCP)

Two Types: 1. Transmitted Trouble Delineation – written for each client; it has 3 columns: nursing diagnoses, expected outcomes &  nursing interventions. 2. Standardized Trouble Delineation – fixed on an state’s standards of practice; thereby helping to furnish a proud attribute of nursing trouble


  • Widely used, neat mode of organizing & proceedingsing grounds environing a client, making knowledge at-once pathible to all bloom professionals. Consists of a order of cards kept in a movable protest polish or on computer generated forms.
Information may be unconfused into exceptions:
  1. Pertinent knowledge environing the client
  2. List of medications
  3. List of IVF
  4. List of daily treatments & procedures
  5. List of Symptom procedures
  6. Allergies
  7. Specific grounds on how the client’s natural want is to be met
  8. A completion register, recognized goals & register of nursing vestibulees to coalesce the goals

Nursing Empty & Referral Summaries

These are perfectd when the client is substance emptyd or infections to another state or to a settlement elucidation where a investigate by a class bloom protect is required. Regardless of format, it embodys some or all of the following:
  1. Description of client’s natural, immaterial & emotional state
  2. Resolved bloom completions
  3. Unresolved abiding bloom completions
  4. Treatments that can be continued (e.g. harm trouble, oxygen therapy)
  5. Current medications
  6. Restrictions that rehearse to temper, victuals & bathing
  7. Functional/self-care abilities
  8. Comfort level
  9. Support networks
  10. Client counsel furnishd in aspect to malady process
  11. Discharge destination
  12. Referral Services (e.g. gregarious worker, settlement bloom protect)

Guidelines for Good Documentation and Reporting

  1. Fact – knowledge environing clients and their trouble must be factual. A proceedings should embody pictorial, concrete knowledge environing what a protect sees, hears, feels and smells
  2. Accuracy – knowledge must be deferential so that bloom team members possess assurance in it
  3. Completeness – the knowledge among a proceedings or a declaration should be perfect, embodying neat and thoroughgoinggoing knowledge environing a client’s trouble. Neat grounds are comfortable to understand
  4. Currentness – ongoing decisions environing trouble must be fixed on currently declarationed knowledge. At the span of event embody the following:
    • a. Vital signs
    • b. Administration of medications and treatments
    • c. Preparation of symptom tests or surgery
    • d. Transmute in foundation
    • e. Admission, assign, empty or mortality of a client
    • f. Treatment for a rash transmute in foundation
  5. Organization – the protect publish in a argumentative format or appoint
  6. Confidentiality – a commissionworthy message is knowledge given by one idiosyncratic to another after a while commission and assurance that such knowledge accomplish not be disclosed


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