Documentation & Records

This category covers the importance, methods, and legal implications of nursing and surgical documentation.

Nursing Documentation

Documentation is a critical aspect of nursing practice.

Purpose of Nursing Documentation

• To provide goal-directed care.
• To record nursing interventions (when, where, by whom).
• To document evaluations of care and patient response.
• To track outcomes.

Documenting Errors on Paper

• Method: Draw a single line through the error, ensuring the original entry remains legible.
• Policy: Further actions are determined by hospital policy.

Timestamps in Electronic Records

• Real-Time Documentation: Document as close to real-time as possible.
• Visibility: Timestamps are visible in every section of the electronic chart.
• Legal Implications: Pre-charting can have negative legal consequences. Never alter a record if it’s involved in a legal case.

Patient Handoffs

• Standardization: Can utilize a standardized handoff tool.
• Documentation: Must document the person, their title, and the location to whom care was transferred.
• Question Time: Allow adequate time for the receiving caregiver to ask questions.

Perioperative Nursing Data Sets (PNDS)

• Function: PNDS are embedded into charting systems, containing surgery-related diagnoses and nursing care plans.
• Benefit: Allows for efficient documentation and integrated nursing care planning.

The Nursing Process (ADPIE)

The Nursing Process is a systematic approach to patient care.

Steps of the Nursing Process

• A – Assessment:
  • Purpose: To gather comprehensive information necessary for patient care.
  • Actions: Collecting vital signs, assessing mobility and NPO status, evaluating communication abilities, checking allergies, conducting chart reviews, examining preference cards, and discussing procedural preferences with the physician. Asking questions specifically for patient care.
  • Outcome: To acquire data for formulating a nursing diagnosis.
• D – Diagnosis:
  • Purpose: To identify and classify the data collected during the assessment phase.
  • Autonomy: Nurses must be able to perform interventions to correct the identified issue without a physician’s order (e.g., actions to maintain skin integrity).
• I – Identification of Outcomes:
  • Purpose: To establish measurable goals that can be achieved through nursing care.
  • Format: Goals are always stated in the future tense (e.g., “Patient will remain free from infection”).
• P – Planning:
  • Purpose: To select the specific nursing interventions that will help achieve the desired outcomes or goals.
  • Actions: Outlining “how to” accomplish the goal (e.g., “how to remain free from infection”). Communicating the plan of care to the patient, family, and healthcare team (e.g., teaching crutch training).
  • Key Indicator: The act of gathering supplies and equipment with the explicit purpose of performing an intervention is considered part of the planning phase.
• I – Implementation:
  • Purpose: To execute the plan of care.
  • Actions: This is the “doing” phase; a verb-driven action performed directly with the patient.
  • Examples: Placing an IV, explaining a surgical procedure.
• E – Evaluation:
  • Purpose: To determine if the established goals were met.
  • Format: Always written in the past tense.
  • Outcome: If goals were not met (e.g., “The patient was not able to ambulate with crutches”), the process cycles back to reassessment and replanning.

NANDA (North American Nursing Diagnosis Association)

• Role: Provides the official list of approved nursing diagnoses.
• Focus: Nursing diagnoses describe a human response to a pathology.
• Types: Can be actual (e.g., “Alteration in skin integrity”) or potential (e.g., “Risk for alteration in skin integrity”).
• Autonomy: Nursing treatment for these diagnoses is designed to correct the issue without requiring a physician’s order.

Charting “By Exception” with PNDS

• When using PNDS embedded charting, nurses are charting “by exception.” This means standard interventions are assumed to be done unless otherwise noted.
• Modification: If standard options are inappropriate, the nurse uses an open text box to document specific actions for that patient. This is an example of modifying the Plan of Care.
• Individualization: Every patient effectively has an individualized Plan of Care because of this “charting by exception” approach with PNDS.

Nursing Process Step for Gathering Supplies/Equipment

• Planning is the nursing process step that involves gathering supplies and equipment with the purpose of performing an action.

Nursing Process Step for Direct Patient Action

• Implementation is the nursing process step that involves directly doing something with the patient, such as starting an IV.
  • (Gathering the supplies for the IV is Planning).