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Nursing Documentation

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by

Cherry Kris Suarez

on 21 October 2013

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Transcript of Nursing Documentation

Notes
DATA
ACTION
RESPONSE
NURSING DOCUMENTATION
Nursing Documentation
Documentation is any written or electronically generated information about a client that describes the care or service provided to that client.
Remember!
All entries must be legible.
Purposes
To facilitate COMMUNICATION
FOCUS Charting
Focus Charting
is a method of organizing health information in the patient's record.
Thank you!
Guiding Principles
Factual
Effective documentation reflects the quality of care and provides evidence of each health care team member's accountability in giving care.
To meet PROFESSIONAL & LEGAL STANDARDS
To promote QUALITY NURSING CARE
Organized
Current
Complete
Accurate
Confidential
D
FOCUS
a sign/symptom,
current individual concern or behavior,
acute change in patient's condition,
a significant event in patient's care,
a key word/phrase indicating compliance with a standard of care or hospital policy,
a NURSING DIAGNOSTIC CATEGORY
focus
data
action
response
R
A
F
It encourages the use of assessment data to evaluate patient concerns.
It is a systematic approach to documenting nursing care organized into patient-centered topics or foci.
Subjective and/or objective information that supports the stated focus or describes the client status at the time of a significant event or intervention.

Completed or planned nursing interventions based on the nurse’s assessment of the client’s status.

Description of the impact of the interventions on client outcomes.

Ineffective airway clearance r/t inability to expectorate secretions
- clear frothy secretions noted; O2Sat 98%; RR=20bpm; crackles still noted on lung auscultation.
-suctioned secretions at 0800H and every 2hours thereafter, -seen by Dr. Mohd at 1000H, no new orders made.
-client semicomatose; excessive oral secretions noted; RR=22bpm; crackles heard over both lung fields
Don't leave blank spaces.
In making corrections, don't use eraser, correction fluid, or blotting out. Draw a line through it and write MISTAKEN ENTRY, with your name.
Each recording must be signed by the nurse making it.
Use only acceptable abbreviations.
All entries on the patient's record must be in permanent ink.
CHERRY KRIS SUAREZ
Nurse Tutor

For EDUCATION & RESEARCH
MISTAKEN ENTRY
LATE ENTRY
Full transcript