Medical Terminology - Quia

NURSING PROCESS Chapter 7 The Nursing Process: Documenting the Nursing Process Reference Doenges, M. E., & Moorhouse, M. F. (2008). Application of nursing process and nursing diagnosis: An interactive text for diagnostic reasoning (5th ed.). Philadelphia: F. A. Davis.

Competencies for Ch 7: Documenting the Nursing Process By the end of this unit the student will: 1. 2. 3. 4. 5. 6. List 7 functions of progress notes Demonstrate descriptive note writing List 5 areas of content to include in a progress

note Describe 5 types or formats of progress notes List items documented on flow sheets Describe purpose and content of reporting and conferring Documentation Written, legal record of all pertinent interactions with the patient Provides a record of the nursing

process used for delivery of individualized care Goals of documentation: Ensure documentation of progress with regard to client outcomes Facilitate interdisciplinary consistency

Communication of treatment goals and progress Progress Notes Progress notes should include all significant events that occur during the clients hospitalization/treatment program 7 major functions of progress notes: Staff communication Evaluation Relationship monitoring Reimbursement Legal documentation Accreditation Training and supervision

Descriptive Note Writing Notes should form a clear picture of what occurred with the client Descriptive or observational statements (statements referring to specific observable or measurable events) ensure clarity of progress notes Descriptive language: - Measurable periods of time - Measurable quantities Descriptive Note Writing

Descriptive language avoids statements that are evaluative or judgmental unless observational evidence can be presented to back up judgment Judgmental Judgmental language can lead to miscommunication statements: - Undefined periods of time - Undefined quantities - Unsupported qualities

- Objective basis for judgments Content of Note/Entry Clients progress Significant observations/information Correct spelling and grammar Brief, specific, short succinct sentences or phrases

Consistent with agency policies Possible Formats of Note / Entry Block notes (single entry covering entire shift) Narrative timed notes (date, time, and event) Charting by exception Problem-oriented medical record (POMR)

Subjective/objective/analysis/plan (SOAP) Subjective/objective/analysis/plan/ implementation/ evaluation/revision (SOAPIER) Problem/intervention/evaluation (PIE) Focus charting Data/action/response (DAR) Flow Sheets

Graphic record (T,P,R,B/P, wt, etc.) Fluid balance record (I&O) Medication record Acuity form Home healthcare documentation Seen in many settings (Often contains check boxes. Streamlined data)

Reporting/Conferring Change of shift report Telephone reports Telephone orders Transfer and discharge reports Reports to family and significant others Incident reports

Nursing care conference Take Home Points Documentation is written verification of nursing care provided Documentation should be brief and specific Documentation should follow facility policy regarding format

Many different documentation formats exist MOST OF ALL. KNOW WHAT YOU ARE DOCUMENTING AND WHY YOU ARE DOCUMENTING IT KNOW THE SIGNIFICANCE OF WHAT YOU ARE WRITING IN RELATION TO PATIENT CARE