SlideShare a Scribd company logo
4
Most read
9
Most read
10
Most read
PRINCIPLES OF DOCUMENTATION Ms. JEENA AEJY
DOCUMENTATION MUST BE CONSISTENT WITH PROFESSIONAL AND AGENCY STANDERDS, COMPLETE, ACCURATE , CONCISE, FACUAL, ORGANIZED AND TIMELY, LENGTHY, PRUDENT AND CONFIDENTIAL.
1. DATE & TIME Document date and time of  each  recording. Record time in conventional manner(Eg. 9am, 6pm etc)  or according to the 24 hour clock(military clock) Avoid recording in advance.
2.LEGIBILITY Entries must be legible and easy to read. Writing must be clear. Very important in recording numbers and medical terms.
3.CORRECT SPELLING Correct spelling is essential for accuracy. If unsure about the spelling use a dictionary or other resource book.
4.PERMANANCE Entries should be  done in dark ink. It helps to identify changes and allows duplication (Xerox).
5.ACCEPTED TERMINOLOGY Use commonly accepted abbreviations, symbols and terms that are specified by the agency Use universally accepted abbreviations.
6.FACTUAL Descriptive objective information about  what nurse sees, hears, feels and smells. Use of inference without supporting data is not acceptable. Vague terms like appears, seems or apparently is not accepted.  Include objective signs of problems. Subjective data is documented in client’s exact words within quotation marks.
7. ACCURATE Use of exact measurement establishes accuracy. Eg. Intake 450ml of water than writing adequate amount of water. Clients name and identifying information is written on each page. Before making any entry in the chart make sure that it is correct. Chart only your observations and actions to be accountable.
If any mistakes occur  while recording, draw a line through it and write above or next to original entry with your initials or name. Do not erase, blot or use correction fluids. Follow agencies policy while making computerized charting. Write on every line but not in between the lines. Draw a line through the blank spaces so that no additional information can be added.
8.SEQUENCE Document events in order of occurrence. Eg. Record assessments, then nsg interventions and then the client responses. Update or delete problems as needed.
9. APPROPRIATENESS Record informations  pertaining to the client health problems& care only. Avoid personal informations that are in appropriate.
10. COMPLETENESS Document all necessary informations It should give a clear picture of what took place. Complete pertinent assessment data such as vital signs, wound drainage, client complaints, who was notified and what interventions are carrid out etc are recorded.
The following informations should be included in the chart: A new or changed information Signs and symptoms Client behavior Nursing interventions Medications Physician’s orders carried out Client teaching Client response
11.CURRENT Timely entries are must Keeping record at bed side may facilitate immediate documentation
Activities/findings recorded at the time of occurrence include the following Vital signs Administration of  drugs or Rx Preparations for diagnostic tests or surgery Change in the clients health status & who was notified. Admission, transfer, discharge or death of a client. Treatement for a sudden change in client’s status.
12. CONCISENESS (BRIEVITY) Recording need to be brief as well as complete to save time in communication. Client’s name and the word client can be omitted Eg. “perspiring profusely. Respiration shallow. 28/mt” Use accepte abbreviations
13. ORGANIZED Information should have logical manner Eg. description of pain, nurses assessment and interventions and the client response. This helps in preventing any omission of informations. Easy to read.
14. SIGNATURE Each recording is signed by the nurse. Signature includes the name and the title  In computerized charting nurse will have his or her own code.
15.CONFIDENTIALITY All the client’s record are confidential files The information in the chart is personal as well as legal. Record shouldn't be copied without the permission of the client. Nurse should not allow any outsiders to verify the client record.
Thank you

More Related Content

PPTX
Pelvic floor muscle and dysfunctions
PPTX
Documentation and reporting
PPT
Physical assessment
PPT
Nursing Documentation
PPTX
Mental illness
PPTX
Types of wounds and management.
PPTX
Pelvic floor muscle and dysfunctions
Documentation and reporting
Physical assessment
Nursing Documentation
Mental illness
Types of wounds and management.

What's hot (20)

PPTX
Documentation and reporting
PPSX
Guidelines for recording and reporting
PPTX
Nursing documentation ppt
PPTX
PROMOTING SAFETY IN HEALTH CARE ENVIRONMENT.pptx
PPTX
REPORTING IN NURSING
PPT
Documentation and Reporting
PPT
Cultural diversity.ppt
PPTX
DOCUMENTATION IN NURSING
PPTX
Self empowerment
PPTX
admission procedure in nursing
PDF
Different Types of Nursing Documentation Methods
PPTX
COMMUNICATION IN NURSING
PPTX
Patient Education.pptx
PPTX
sensory component
PPTX
Mobility and immobility
PDF
Unit 10 Promoting Safety in Health Care Enevronment (FON).pdf
PPT
Roles of the Nurse
PPTX
Patient safety Devices - Restraints
PPSX
Transfer of patient
PPTX
Implementation in nursing process
Documentation and reporting
Guidelines for recording and reporting
Nursing documentation ppt
PROMOTING SAFETY IN HEALTH CARE ENVIRONMENT.pptx
REPORTING IN NURSING
Documentation and Reporting
Cultural diversity.ppt
DOCUMENTATION IN NURSING
Self empowerment
admission procedure in nursing
Different Types of Nursing Documentation Methods
COMMUNICATION IN NURSING
Patient Education.pptx
sensory component
Mobility and immobility
Unit 10 Promoting Safety in Health Care Enevronment (FON).pdf
Roles of the Nurse
Patient safety Devices - Restraints
Transfer of patient
Implementation in nursing process
Ad

Viewers also liked (11)

PPTX
Importance of documentation to system analysis
PPT
Nursing Skills: Charting
PDF
Report & its types
PPT
nursing documentation
PPTX
Methods of nursing documentation final
PPS
Documentation Types
PPT
What is documentation and its techniques
PPTX
Good documentation practice
PPT
Nursing records & reports
Importance of documentation to system analysis
Nursing Skills: Charting
Report & its types
nursing documentation
Methods of nursing documentation final
Documentation Types
What is documentation and its techniques
Good documentation practice
Nursing records & reports
Ad

Similar to Principles of Documentation (20)

PPT
Documentation-and-Reporting students sharing.ppt
PPTX
PPT
Documentation IKFKJRENJKBGKJBKRJKJTRBKJRK
PPT
Documentation-and-Reporting . Ppt for bsc nursing students
PPT
Documentation-and-Reporting.ppt
PPT
Documentation-and-Reporting.ppt
PPTX
Documentation-and-Reporting in medical services
PPT
Documenting And Reporting
PPTX
Documentation &.pptx
PDF
Maintenance of records and reports copy
PPT
Documenting and reporting
PPTX
records and reports.pptx
PPTX
NURSING INFORMATICS.pptx
PPTX
DOCUMENTATION FOR THE NURSES IN THE HOSPITAL.pptx
DOCX
Quality medical records for the nursing service
PDF
Significance of Accurate Discharge Summary and Error-free EHR
PPT
Pt assess documentation
PDF
Section 7: Client Consultation and Aftercare.pdf
PPT
DOCUMENTATION AND REPORT WRITING ........ppt
PDF
Why Good Medical Record Keeping Is important for Nurses
Documentation-and-Reporting students sharing.ppt
Documentation IKFKJRENJKBGKJBKRJKJTRBKJRK
Documentation-and-Reporting . Ppt for bsc nursing students
Documentation-and-Reporting.ppt
Documentation-and-Reporting.ppt
Documentation-and-Reporting in medical services
Documenting And Reporting
Documentation &.pptx
Maintenance of records and reports copy
Documenting and reporting
records and reports.pptx
NURSING INFORMATICS.pptx
DOCUMENTATION FOR THE NURSES IN THE HOSPITAL.pptx
Quality medical records for the nursing service
Significance of Accurate Discharge Summary and Error-free EHR
Pt assess documentation
Section 7: Client Consultation and Aftercare.pdf
DOCUMENTATION AND REPORT WRITING ........ppt
Why Good Medical Record Keeping Is important for Nurses

More from JEENA AEJY (20)

PPSX
WHAT I LEARNED IN LIFE
PPSX
MIND WITHOUT FEAR.
PPSX
Awareness
PPSX
Christmas is here
PPSX
Will you leave the Flowers for the Crown..?
PPSX
HOSANNA IN THE HIGHEST
PPSX
Happiness
PPSX
Its Raining...!!!!
PPT
Factors Affecting Growth & Development of children
PPT
PPT
PANEL DISCUSSION
PPT
Oxygen Therapy
PPT
Models
PPT
Project As A Method Of Teaching
PPT
Puppets
PPT
Communication
PPT
NURSING PROCESS
PPT
Culture
PPT
Spirituality
PPT
TETRALOGY OF FALLOT, PARENT TEACHING
WHAT I LEARNED IN LIFE
MIND WITHOUT FEAR.
Awareness
Christmas is here
Will you leave the Flowers for the Crown..?
HOSANNA IN THE HIGHEST
Happiness
Its Raining...!!!!
Factors Affecting Growth & Development of children
PANEL DISCUSSION
Oxygen Therapy
Models
Project As A Method Of Teaching
Puppets
Communication
NURSING PROCESS
Culture
Spirituality
TETRALOGY OF FALLOT, PARENT TEACHING

Recently uploaded (20)

PDF
Deadly Stampede at Yaounde’s Olembe Stadium Forensic.pdf
PPTX
Neurotransmitter, Types of neurotransmitters,Neurotransmitter function, Neur...
PPT
genitourinary-cancers_1.ppt Nursing care of clients with GU cancer
PPTX
POLYCYSTIC OVARIAN SYNDROME.pptx by Dr( med) Charles Amoateng
PPTX
neonatal infection(7392992y282939y5.pptx
PPTX
CME 2 Acute Chest Pain preentation for education
PDF
Neuro ED Bet Sexologist in Patna Bihar India Dr. Sunil Dubey
PPTX
Fundamentals of human energy transfer .pptx
PDF
Therapeutic Potential of Citrus Flavonoids in Metabolic Inflammation and Ins...
PPTX
Chapter-1-The-Human-Body-Orientation-Edited-55-slides.pptx
PPTX
Respiratory drugs, drugs acting on the respi system
PPTX
NEET PG 2025: Memory-Based Recall Questions Compiled by Dr. Shivankan Kakkar, MD
PPTX
ca esophagus molecula biology detailaed molecular biology of tumors of esophagus
PPTX
Electromyography (EMG) in Physiotherapy: Principles, Procedure & Clinical App...
PPTX
Pathophysiology And Clinical Features Of Peripheral Nervous System .pptx
PPTX
JUVENILE NASOPHARYNGEAL ANGIOFIBROMA.pptx
PPTX
Uterus anatomy embryology, and clinical aspects
PDF
Rheumatoid arthritis RA_and_the_liver Prof AbdelAzeim Elhefny Ain Shams Univ...
PPTX
1 General Principles of Radiotherapy.pptx
PDF
CT Anatomy for Radiotherapy.pdf eryuioooop
Deadly Stampede at Yaounde’s Olembe Stadium Forensic.pdf
Neurotransmitter, Types of neurotransmitters,Neurotransmitter function, Neur...
genitourinary-cancers_1.ppt Nursing care of clients with GU cancer
POLYCYSTIC OVARIAN SYNDROME.pptx by Dr( med) Charles Amoateng
neonatal infection(7392992y282939y5.pptx
CME 2 Acute Chest Pain preentation for education
Neuro ED Bet Sexologist in Patna Bihar India Dr. Sunil Dubey
Fundamentals of human energy transfer .pptx
Therapeutic Potential of Citrus Flavonoids in Metabolic Inflammation and Ins...
Chapter-1-The-Human-Body-Orientation-Edited-55-slides.pptx
Respiratory drugs, drugs acting on the respi system
NEET PG 2025: Memory-Based Recall Questions Compiled by Dr. Shivankan Kakkar, MD
ca esophagus molecula biology detailaed molecular biology of tumors of esophagus
Electromyography (EMG) in Physiotherapy: Principles, Procedure & Clinical App...
Pathophysiology And Clinical Features Of Peripheral Nervous System .pptx
JUVENILE NASOPHARYNGEAL ANGIOFIBROMA.pptx
Uterus anatomy embryology, and clinical aspects
Rheumatoid arthritis RA_and_the_liver Prof AbdelAzeim Elhefny Ain Shams Univ...
1 General Principles of Radiotherapy.pptx
CT Anatomy for Radiotherapy.pdf eryuioooop

Principles of Documentation

  • 2. DOCUMENTATION MUST BE CONSISTENT WITH PROFESSIONAL AND AGENCY STANDERDS, COMPLETE, ACCURATE , CONCISE, FACUAL, ORGANIZED AND TIMELY, LENGTHY, PRUDENT AND CONFIDENTIAL.
  • 3. 1. DATE & TIME Document date and time of each recording. Record time in conventional manner(Eg. 9am, 6pm etc) or according to the 24 hour clock(military clock) Avoid recording in advance.
  • 4. 2.LEGIBILITY Entries must be legible and easy to read. Writing must be clear. Very important in recording numbers and medical terms.
  • 5. 3.CORRECT SPELLING Correct spelling is essential for accuracy. If unsure about the spelling use a dictionary or other resource book.
  • 6. 4.PERMANANCE Entries should be done in dark ink. It helps to identify changes and allows duplication (Xerox).
  • 7. 5.ACCEPTED TERMINOLOGY Use commonly accepted abbreviations, symbols and terms that are specified by the agency Use universally accepted abbreviations.
  • 8. 6.FACTUAL Descriptive objective information about what nurse sees, hears, feels and smells. Use of inference without supporting data is not acceptable. Vague terms like appears, seems or apparently is not accepted. Include objective signs of problems. Subjective data is documented in client’s exact words within quotation marks.
  • 9. 7. ACCURATE Use of exact measurement establishes accuracy. Eg. Intake 450ml of water than writing adequate amount of water. Clients name and identifying information is written on each page. Before making any entry in the chart make sure that it is correct. Chart only your observations and actions to be accountable.
  • 10. If any mistakes occur while recording, draw a line through it and write above or next to original entry with your initials or name. Do not erase, blot or use correction fluids. Follow agencies policy while making computerized charting. Write on every line but not in between the lines. Draw a line through the blank spaces so that no additional information can be added.
  • 11. 8.SEQUENCE Document events in order of occurrence. Eg. Record assessments, then nsg interventions and then the client responses. Update or delete problems as needed.
  • 12. 9. APPROPRIATENESS Record informations pertaining to the client health problems& care only. Avoid personal informations that are in appropriate.
  • 13. 10. COMPLETENESS Document all necessary informations It should give a clear picture of what took place. Complete pertinent assessment data such as vital signs, wound drainage, client complaints, who was notified and what interventions are carrid out etc are recorded.
  • 14. The following informations should be included in the chart: A new or changed information Signs and symptoms Client behavior Nursing interventions Medications Physician’s orders carried out Client teaching Client response
  • 15. 11.CURRENT Timely entries are must Keeping record at bed side may facilitate immediate documentation
  • 16. Activities/findings recorded at the time of occurrence include the following Vital signs Administration of drugs or Rx Preparations for diagnostic tests or surgery Change in the clients health status & who was notified. Admission, transfer, discharge or death of a client. Treatement for a sudden change in client’s status.
  • 17. 12. CONCISENESS (BRIEVITY) Recording need to be brief as well as complete to save time in communication. Client’s name and the word client can be omitted Eg. “perspiring profusely. Respiration shallow. 28/mt” Use accepte abbreviations
  • 18. 13. ORGANIZED Information should have logical manner Eg. description of pain, nurses assessment and interventions and the client response. This helps in preventing any omission of informations. Easy to read.
  • 19. 14. SIGNATURE Each recording is signed by the nurse. Signature includes the name and the title In computerized charting nurse will have his or her own code.
  • 20. 15.CONFIDENTIALITY All the client’s record are confidential files The information in the chart is personal as well as legal. Record shouldn't be copied without the permission of the client. Nurse should not allow any outsiders to verify the client record.