2. To be able to understand
the differences in Methods
of Documentation.

3.  Documentation is any written or electronically
generated information about a client that
describes the care or service provided to that
client.

4. Written evidence of:
 The interactions between and among health care
professionals, clients, their families, and health care
organizations.
 The administration of tests, procedures, treatments,
and client education.
 The results of, or client’s response to, diagnostic tests
and interventions.

5.  nurses communicate to other nurses and care
providers their assessments about the status of clients,
nursing interventions that are carried out and the
results of these interventions.
 Thorough, accurate documentation decreases the
potential for miscommunication and errors.

6.  Encourages nurses to assess client progress and
determine which interventions are effective and which
are ineffective, and identify and document changes to
the plan of care as needed.
 facilitating nursing research, all of which have the
potential to improve the quality of nursing practice and
client care.

7.  Documentation is a valuable method for
demonstrating that, within the nurse-client
relationship, the nurse has applied nursing
knowledge, skills and judgment according to
professional standards.
 The nurse’s documentation may be used as evidence
in legal proceedings such as lawsuits, coroners’
inquests, and disciplinary hearings through
professional regulatory bodies.

8. A. USE A COMMON VOCABULARY.
B. WRITE LEGIBLY & NEATLY
C. USE ONLY AUTHORIZED ABBREVIATIONS &
SYMBOLS. (e.g.; t.i.d, b.i.d, q.i.d, p.r.n, p.o, p.c, a.c,
h.s.)
D. EMPLOY FACTUAL & TIME SEQUENCE
ORGANIZATION
E. DOCUMENT ACCURATELY & COMPLETELY,
INCLUDING ANY ERRORS.

9. A. ASSESSMENT
B. NURSING DIAGNOSIS
C. PLANNING (S.M.A.R.T.)
D. IMPLEMENTATION
E. EVALUATION

10.  Kardexes are used to communicate current orders,
upcoming tests or surgeries, special diets or the use of
aids for independent living specific to an individual
client; Usually contains:
◦ Client data (name, age, marital status, religious
preference, physician, family contact).
◦ Medical diagnoses: listed by priority.
◦ Allergies.
◦ Medical orders (diet, IV therapy, etc.).
◦ Activities permitted.

12.  Flow sheets and checklists are used to
document routine care and observations
that are recorded on a regular basis
 (e.g., activities of daily living, vital signs,
intake and output).

16.  Used to document:
◦ Client’s condition, problems, and complaints.
◦ Interventions.
◦ Client’s response to interventions.
◦ Achievement of outcomes.


17. DATE TIME NURSES NOTES SIGNATURE

18. Highlights client’s illness and course of care.
Includes:
◦ Client’s status at admission and discharge.
◦ Brief summary of client’s care.
◦ Intervention and education outcomes.
◦ Resolved problems and continuing care needs.
◦ Client instructions regarding medications, diet,
food-drug interactions, activity, treatments,
follow-up and other special needs.

19. A. SOAP/SOAPIE(R) CHARTING
B. NARRATIVE CHARTING
C. FOCUS CHARTING

20.  SOAP/SOAPIE(R) charting is a problem-
oriented approach to documentation
whereby the nurse identifies and lists
client problems; documentation then
follows according to the identified
problems.

21.  S = Subjective data (e.g., how does the client feel?)
 O =Objective data (e.g., results of the physical exam,
relevant vital signs)
 A = Assessment (e.g., what is the client’s status?)
 P =Plan (e.g., does the plan stay the same? is a change
needed?)
 I =Intervention (e.g., what occurred? what did the nurse
do?)
 E=Evaluation (e.g., what is the client outcome following the
intervention?)
 R =Revision (e.g., what changes are needed to the care
plan?)

22. S: “I feel weak & tired” as verbalized by the patient
O:Received on bed on supine position conscious and coherent, with intact and
unsoaked incision dressing, (-) breast engorgement, urine (1), (-)BM, unsoaked
vaginal/perineal pads with moderate amount of lochia serosa, (-)Homan’ssign,
ambulatory, pale buccal mucosa and conjunctiva, hgb count (77), hct
(0.33),with initial vital signs taken as follows:BP- 120/80 mmHg, PR-83 bpm,
RR-26bpm, Temp.-36.4oC.
A:Altered Tissue Perfusion r/t decrease hgb(77), hct(0.33) counts
P: After 2o of nursing intervention, the patient will verbalize understanding of the
condition, treatment/therapy regimen, and will demonstrate behavioral changes
to improve circulation.
I: Assessed for physical manifestations of anemia. Assessed for factors that could
precipitate to anemia such as bleeding on incision site, excessive lochia and
diet. Assessed diet/food preference. Encouraged to increase intake of food
rich in iron such as animal liver & green & leafy vegetables when in DAT
status. Instructed to watch for sign of bleeding on incision site (soaked
dressing) and increase in lochia. Instructed compliance to oral iron supplement
intake. Administered due medication
E:Patient verbalized understanding of condition and therapeutic regimen and
demonstrated behavioral changes to improve circulation

23.  Narrative charting is a method in which nursing
interventions and the impact of these interventions on
client outcomes are recorded in chronological order
covering a specific time frame.
 Data is recorded in the progress notes, often without
an organizing framework.
 Narrative charting may stand alone or it may be
complemented by other tools, such as flow sheets and
checklists.

24. 0730H Admitted patient to Emergency Room male 50 years old, conscious, immobile with
chief complaints of numbness in Left side of the body.
Difficulty of breathing slightly noted
With evidence of Slurred speech, Leg edematous.
Left side of the body is unresponsive to pain stimuli
Initial vital signs taken as follows: SPO2 75%; BP 200/110mmHg; 90bpm; RR
24cpm; Temp 38.5C; Weight 150Kg.
0735H Oxygen inhalation started @ 4LPM via nasal cannula.
Seen and examined by Attending Physician-Dr. Salazar with orders made and
0740H carried out.
For MRI, Chest X-Ray (AP) & Lab Investigation- requested.
0745H Foley Catheter F#16 inserted aseptically and attached to Urobag- draining well with
yellow colored urine..
Vital Sign monitored every 15 minutes & I & O measured every hour.
0746H Venoclysis Started with IVF of Plain NSS 1 Liter and regulated at KVO rate .
0747H Furosemide 40mg given via slow IV push.
Citicoline 100mg loading dose started via IV then every 6 hours after.
Fixed and wheeled to ward per stretcher with same IVF on.
0800H Endorsed.-------------------------------------NESTOR A. SALAZAR JR., RN.

25.  method of documentation, in which
the nurse identifies a “focus” based
on client concerns or behaviors
determined during the assessment.

26. F - FOCUS
D - DATA (subjective/objective)
A - ACTION
R - RESPONSE

27.  • Flexible enough to adapt to any clinical practice setting
and promotes interdisciplinary documentation
 • Centers on the nursing process, including assessment,
planning, implementation and evaluation
 • Information is easy to find because data is organized by
the focus.
 • It promotes communication between all care team
members
 • Encourages regular documentation of patient responses to
care
 • Helps organize documentation so that it is concise and
precise
 • Can be easily adapted to computer based documentation
systems

28. REFERS TO EXAMPLE
A sign or Symptom Hypotention, or Chest Pain
A patient behavior Inability to ambulate
An acute change in the patient condition LOC, or ICP
A significant event in the patient’s therapy Surgery(e.g “E” Appendectomy)
A special patient need Discharge planning need

29. DATE TIME
4/10/11 1200H F- Wound dressing
D- Moderate amount, foul smelling drainage from abdominal
incision noted. Suture line red swollen and warm to touch; T-39.5C,
complaining of pain at the site.-------------------------NESTOR A. SALAZAR JR., RN
A- Dr. N. Salazar notified and informed of patient’s incisional
status, orders received. Ketorolac 30mg given via IV as ordered,
C&S of wound taken and sent to Lab. Wound cleansed with
antibacterial solution and dry dressing applied.------NESTOR A. SALAZAR JR., RN
R- Temp. rechecked- 38C. Patients states incisional pain improving.
Dressing remains dry & intact, no discharge noted. Antibiotic
initiated as ordered.--------------------------------------NESTOR A. SALAZAR JR., RN

30. In which of the 3 Methods of
Documentation you are going to
use in making Nurses Notes for
the Patient? Why?