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Common Questions in Documentation

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donabelle laranjo

on 22 July 2016

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Transcript of Common Questions in Documentation

There is currently considerable interest throughout the world within the healthcare sector to increase the quality of nursing documentation--through creating new systems, re-evaluate systems and analyzing reasons for poor compliance of nurses to document.
One reason for the emphasis on nursing documentation may be the increasing need for secure and accurate transfer of patient related information between healthcare providers. The patient record is a principal source of information in which the nursing documentation of patient care is an essential component.
• All medical records entries:
- Written in English using a blue ink ballpen.
- Time of entry using 24 hours clock
e.g. 0800H
- Date of entry using (dd/mm/yy)
• Progress notes are written at least daily and
for any change or deterioration in the
patient's medical condition.
• For long entry that will include another page,
write "continue on next page," on the next
page "continue from previous page."


Medication Administration:
Write date, time and initial
Write full name of responsible person and initial at the bottom of the medication sheet.
When medication is withheld or not given, encircle the initial in the space provided in MAR. Document in the nurses' notes and the reason why it was not given.

Clinical Documentation
is a permanent legal document of patient information and care rendered by a health care provider.
is an addition or attachment to written documentation.
is the authorized person/user that made the entries in the medical records.
is the process that ensures that users are the one who made entry in the patient's medical record. Each entry with stamped, signed, dated and timed by the author.

Correction must be made by making a single line through the error, write "mistaken entry" or ME above, note down the correct data, initialed/signed that made the entry. This is applicable to all entries in the medical records.
Add the entry to the first available line.
Label the entry "Late entry".
Record date and time of entry.
Nursing documentation is an integral part of clinical documentation and is a fundamental nursing responsibility.
Ensures continuity of care furnishes legal evidence of the process of care and supports evaluation of patient of care.
Narrative documentations.

- Assessment
- Nursing diagnosis and patient
- Interventions
- Care provided
- Patient response to care
- Patient's ability to manage
continuing care after discharge

Importance of using proper
- Misspelled words and poor grammar
create a negative impression.
- Readers may infer that a person with
poor spelling and grammar is
uneducated and careless.
- Facilitate communication.
- Promote good nursing care.
- Meet professional legal standards.

in Nursing Documentation
in Nursing Documentation
Check that you have the correct chart before you begin writing.
Write clearly, accurately & legibly
Use hospital's approved abbreviations & symbols.
Document all procedures performed with complete description including patient's outcome.
Chart patient care at the time you provided it.
Document complete information about medication to provide concise information of nursing actions rendered to patient.
Chart the time you gave a medication, the administration route and the patient's response.
Chart precautions or preventive measures used. Record each phone call to physician including the exact time care at the time you provide.

in Nursing Documetnation
Don't chart a symptom such as "c/o pain"
Don't alter a patient's record. Erasures and fluid correctors are not acceptable.
Don't use shorthand or abbreviations that are not widely accepted.
Don't write imprecise descriptions.
Don't give excuses.
Don't chart what someone else said, heard, felt or smelled unless the information is critical.
Don't chart ahead of time.
Don't leave any blank space in patient's MR.

All individuals having contact with medical records and medical record information are expected to:
Safeguard the record and all information.
Discussion of confidential information and communicating confidential patient information inappropriately, carelessly or negligently may cause a disciplinary action/dismissal.
No information can be released for purpose other than continuity of care.
By Hanan Mana Al Grad, MCHN Assistant Nursing Director
MCHN Policies & Procedures
IPP MR-005:
Medical Records Documentation & Authorized Person to have Access & make Entries
IPP MR-012:
Confidentiality, Integrity & Security of Patient Record & Release of Patient Information.
Why do we need to document?
How to Document in Medication
How to make corrections in medical record
How are we going to make a late entry?
What is Nursing Documentation?
What are the rules in documentation?
What is Confidentiality?
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