Nursing process and documentation

NURSING PROCESS/
DOCUMENTATION

THE NURSING PROCESS
Includes 5 steps:
1. Assessment
2. Diagnosis
3. Planning and outcome identification
4. Implementation
5. Evaluation

THE NURSING
PROCESS (continued)
 A series of steps that lead to
accomplishing some goal or purpose.
 A systematic method for providing
care to clients.
 Provides individualized, holistic,
effective and efficient client care.
 Clients of all ages and in any care
setting.

ASSESSMENT
 The first step in the nursing process.
 Includes systematic collection,
verification, organization,
interpretation, and documentation of
data.

THE PURPOSE
OF ASSESSMENT
 To organize a database regarding a
client’s physical, psychosocial, and
emotional health.
 To identify health-promoting
behaviors and actual and/or potential
health problems.

TYPES OF ASSESSMENT
 Comprehensive–provides baseline
client data.
 Focused–limited to a particular
need or health care concern.
 Ongoing–includes systematic
monitoring of specific problems.

SOURCES OF DATA
 Primary source–client or the major
provider of information about a client.
 Secondary source–sources of data
other than client and include family
members, other health care providers,
and medical records.

TYPES OF DATA
 Subjective data–data from client’s
point of view, and include perceptions,
feelings, and concerns. Collected by
interview.
 Objective data–observable and
measurable, obtained through both
physical examination and the results
of lab and diagnostic testing.

VALIDATING THE DATA
 Prevents misunderstandings,
omissions, and incorrect inferences
and conclusions.

ORGANIZING THE DATA
 Data must be organized.
 Data clustering is the process of
putting the data together in order
to identify areas of the client’s
problems and strengths.

INTERPRETING THE DATA
 Organizing data in clusters helps to
recognize patterns of response or
behavior:
 Distinguish between relevant, irrelevant.
 Determine whether and where there are
gaps in the data.
 Identify patterns of cause and effect.

DOCUMENTING THE DATA
 The nurse must decide which data
should be immediately reported and
which data can just be recorded.
 It is essential for accurate and
complete recording of assessment
data to communicate information to
other health care team members.

DIAGNOSIS
 Second step in the nursing process.
 Clinical judgment about individual,
family, or community response to
actual or potential health
problems/life processes.
 Provides the basis for client care
through the remaining steps.

MEDICAL DIAGNOSIS
 Clients have both nursing and medical
diagnoses.
 A medical diagnosis is a clinical
judgment by the physician that
identifies or determines a specific
disease, condition, or pathological
state.

TWO-PART
NURSING DIAGNOSIS
 Part one–problem statement or
diagnostic label describing the client’s
response to actual or risk health
problem or wellness condition.
 Part two–etiology or the related
cause or contributor to the problem.
 Linked by the term related to (r/t).

THREE-PART
NURSING DIAGNOSIS
 Part one–diagnostic label.
 Part two–etiology.
 Part three–defining characteristics, or
signs and symptoms, subjective and
objective data, or clinical
manifestations.
 Third part linked to the first two by
the term as evidenced by (AEB).

TYPES OF
NURSING DIAGNOSES
 Actual nursing diagnosis–indicates
that problem exists.
 Risk nursing diagnosis–indicates that
specific risk factors are present.
 Wellness nursing diagnosis–client’s
statement of desire to attain a higher
level of wellness in some area of
function.

PLANNING AND
OUTCOME IDENTIFICATION
 Third step of the nursing process.
 Includes establishing guidelines for
the proposed course of nursing action
and developing the client’s plan of
care.

PLANNING PHASES
 Initial planning–developing a
preliminary plan of care.
 Ongoing planning–updating the
client’s plan of care.
 Discharge planning–anticipating and
planning for the client’s needs after
discharge.

PLANNING INVOLVES …
 Prioritizing the nursing diagnoses.
 Identifying and writing client-centered
long- and short-term goals and
outcomes.
 Identifying specific nursing
interventions.
 Recording the entire nursing care plan
in the client’s record.

NURSING INTERVENTIONS
 Actions performed by nurse to help
client achieve results specified by
goals and expected outcomes.
 Refer directly to the related factors or
the risk factors in nursing diagnoses.
 Are stated in specific terms.
 May change.

CATEGORIES OF
NURSING INTERVENTIONS
 Independent–initiated by the nurse
and
do not require an order.
 Interdependent–implemented in a
collaborative manner by nurse in
conjunction with other health care
professionals.
 Dependent–requires an order.

THE NURSING CARE PLAN
 Written guide of strategies to be
implemented to help client achieve
optimal health.
 Begins on the day of admission and
continues until discharge.

IMPLEMENTATION
 Fourth step in the nursing process.
 The performance of the nursing
interventions identified during the
planning phase.

ORDERS FOR INTERVENTIONS
 Specific order–for individual client.
 Standing order–standardized
intervention written, approved, and
signed by a physician, kept on file to
be used in predictable situations.
 Protocol–series of standing orders or
procedures.

EVALUATION
 Fifth step in the nursing process.
 Determines whether client goals have
been met, partially met, or not met.
 Ongoing evaluation is essential for the
nursing process to be implemented
appropriately.

THE NURSING PROCESS
AND CRITICAL THINKING
 Critical thinkers ask questions,
identify assumptions, evaluate
evidence, examine alternatives, and
seek to understand various points of
view.
 Critical thinking can be learned.

DOCUMENTATION
 Any printed or written record of
activities.
 Recording and reporting are the
major ways health care providers
communicate.
 The client’s medical record is a legal
document of all activities regarding
client care.

PURPOSES OF DOCUMENTATION
 Communication
 Practice and legal standards
 Reimbursement
 Education
 Research
 Nursing audit

COMMUNICATION
 Documentation confirms the care
provided to the client and clearly
outlines all important information
regarding the client.

PRACTICE AND
LEGAL STANDARDS
The legal aspects of documentation
require:
 Writing legible and neat
 Spelling and grammar properly used
 Authorized abbreviations used
 Time-sequenced factual and
descriptive entries

PRACTICE
STANDARDS INCLUDE:
 State Nursing Practice Acts
 Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)
 Confidentiality
 Informed consent
 Advance Directives

REIMBURSEMENT
 The federal government requires
monitoring and evaluation of quality,
appropriateness of care provided.
 Documentation of intensity of services
and severity of illness reviewed.
 Failure to document can result in
reimbursement denied.

EDUCATION
 Health care students use medical
record as tool to learn about disease
processes, nursing diagnoses,
complications and interventions.
 Students can enhance critical-thinking
skills by examining the records and
following health care team’s plan of
care.

RESEARCH
 The client’s medical record is used
by researchers to determine whether
a client meets the research criteria
for a study.
 Documentation can also indicate a
need for research.

NURSING AUDIT
 Method of evaluating the quality of
care
 Includes:
 Safety measures
 Treatment interventions and responses
 Expected outcomes
 Client teaching
 Discharge planning
 Adequate staffing

PRINCIPLES OF EFFECTIVE
DOCUMENTATION
1. Document accurately, completely,
and objectively, including any errors.
2. Note date and time.
3. Use appropriate forms.
4. Identify the client.
5. Write in ink.
6. Use standard abbreviations.

PRINCIPLES OF EFFECTIVE
DOCUMENTATION (continued)
7. Spell correctly.
8. Write legibly.
9. Correct errors properly.
10.Write on every line.
11.Chart omissions.
12.Sign each entry.

SYSTEMS OF DOCUMENTATION
 Narrative charting
 Source-oriented
charting
 Problem-oriented
charting
 PIE charting
 Focus charting
 Charting by
exception
 Computerized
documentation
 Critical pathways

NARRATIVE CHARTING
 Traditional method of nursing
documentation.
 Chronologic account in paragraphs
describing client status, interventions
and treatments, and client’s response.
 The most flexible system.
 Usable in any clinical setting.

SOURCE-ORIENTED CHARTING
 Narrative recording by each
member of the health care team on
separate documents.

PROBLEM-ORIENTED CHARTING
 SOAP, SOAPI, AND SOAPIER
 S: subjective data
 O: objective data
 A: assessment data
 P: plan
 I: implementation
 E: evaluation
 R: revision

PIE CHARTING
 P:problem
 I: intervention
 E:evaluation

FOCUS CHARTING
 System using a column format to
chart Data, Action, and Response
(DAR).

CHARTING BY EXCEPTION
 Only significant findings (exceptions)
are documented in a narrative form.
 Presumes that unless documented
otherwise, all standardized protocols
have been met and no further
documentation is needed.

COMPUTERIZED DOCUMENTATION
 Reduces time taken, increases
accuracy.
 Increases legibility.
 Stores, retrieves information quickly.
 Improves communication among
health care departments.
 Confidentiality and costs can be
problems.

CRITICAL PATHWAY
 Also known as Care Maps.
 Comprehensive pre-printed standard
plan reflecting ideal course of
treatment for diagnosis or procedure,
especially with relatively predictable
outcomes.
 Additional forms are needed to
complement the pathway.

NURSE’S PROGRESS NOTES
 Document client’s condition,
problems, complaints, interventions,
and client’s response to
interventions.
 Include MAR, vital signs records,
flow sheets, and intake and output
forms.

DISCHARGE SUMMARY
 Client status on admission and
discharge
 Brief summary of the client’s care
 Intervention and education outcomes
 Resolved and unresolved problems
 Client instructions about medications,
diet, food-drug interactions, activity,
treatments, follow-up, and other
needs

DOCUMENTATION TRENDS
 Nursing Minimum Data Set (NMDS)
 Nursing Diagnoses
 Nursing Interventions Classification
(NIC)
 Nursing Outcomes Classification
(NOC)

INFORMATION
FOR SHIFT REPORT
 Name, room and
bed, age, gender
 Physician,
admission date,
and diagnosis
 Diagnostic tests or
treatments
performed in past
24 hours (results if
ready)
 General status, any
significant change
 New or changed
physician’s orders
 IV fluid amounts,
last PRN medication
 Concerns about
client

TELEPHONE ORDERS
 Date and time
 Order as given by the physician
 Signature beginning with t.o.
(telephone order)
 Physician’s name
 Nurse’s signature
 Physician must countersign

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Nursing process and documentation

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Nursing process and documentation