Lakhasly

Introduction:
Documentation of patient records is key to all areas of nursing practice.
Effective documentation requires clear ‚concise accurate recording of all client and other significant events in an organized and chronologic fashion representative of each phase of the nursing process.

Computerized Records
(Documenting by Computer)
Log off the computer if you are not using it.
Retrieve any printouts immediately.
Ensure that there is a proper back up system of
charting. (security system)
Standards of Nursing Documentation
Computerized Charting
Has become one of the most widespread trends in nursing
documentation.
E. g Kardex is used as reference through out the shift and during change- of shift reports.
Definition
Written evidence of interoctions between and among health professionals clients. their families and health care organizations administration of tests, procedures treatments, and client education and result of or client's response to, diagnostic tests and interventions Eggland & Heinemann. 1994)
Standards of Nursing Documentation
10) Use only standard and institution's approved abbreviations. Do not use shorthand writing.
(11) Do not alter previous documented pt. records.
(12) All documentations must be eligible, relevant, accurate & concise (e.g. clear hand writing).
(13) Do not transcribe physician's orders.
Characteristics of
Docurentation
Well-documented medical record must:
Reflect patients care given.
Demonstrate the expected outcomes of treatment.

• Help to plan & coordinate care contributed by each members of professional team.
  Allow multi-exchange of information about the patient.
  Provide evidence of nurse's legal responsibilities.
  Demonstrate according to rules & regulations of MOH.
  Provide information for cost-benefit & reduction.
  Reflect ethical & professional conduct and responsibility
  Standards of Nursing Documentation
  (1) Use only your institution's approved forms. Do not improvise or introduce new forms unless approved by your health institution.
  (2) All nursing documentation must be written in black or blue ink (including narcotics & blood transfusion)
  (3) Place the patient identification (sticker) on every page or record patient's identification on each page (full name, age, sex, hospital no., bed no……..etc)
  (4) Use standard date at the beginning of each shift (day, month and year).
  Standards of Nursing Documentation
  (5) Use military time for each entry e.g.. 1800 hours.
  (6) Each entry must be authenticated (name, sig..
  title)
  (7) Unfinished documentation should be signed before starting a new page.
  (8) Do not leave blank space between entries.
  (09) Do not erase or obliterate error. Draw a line through an error, write 'error', date and initialize.
  Policy on Verbal Order
  Documentation
  Carefully follow your institutional policy for
  Verbal orders art on We del stded when no
  physicians are available on site and in case of emergency.
  For documenting verbal orders, follow this procedure:
  • Record date and time of the call.
  Dr. name & "T/O" = telephone order or V/O.
  Verbal order should be written word by word.
  If time allow, another nurse repeat the order to Dr.
  • Document that you repeat it again, to sure accurateness.
  Write your name & signature.