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Chapter: 11th Nursing : Chapter 13 : Documentation

Principles of Nursing Documentation

Be specific and definite in using words or phrases that convey the meaning you wish expressed

Principles of Documentation

Accuracy in charting

·           Be specific and definite in using words or phrases that convey the meaning you wish expressed

·           Words that have ambiguous meanings and slang should not be used in charting

·           Chart objective facts, not your interpretations or opinions

  Ate 50% of the food served.

X Ate with poor appetite.

  Refused medications.

X Uncooperative.

Seen crying.

X Depressed.

KEY;

= correct

X = Wrong

Place the complaint of the client in quotation marks to indicate that it is his statement.


Date and Time

Document the date and time of each recording.

Correct Spelling

It is essential for accuracy in recording.

Appropriateness

Record only information that pertains to the client’s health problems and care.

Legal Protection

Accurate complete documentation will give legal protection to the nurse other health care professional of the institution and the client.

Accuracy

Client’s name and identification data must be written on each page of the clients records and entries must be accurate.

Completeness

Document all information necessary to explain the events in a shift. Anyone reading the document should have a clear picture of what took place.

Brief

Only standard medical and nursing terminology and community recognized abbreviations and symbols should be used.

Organizations

Recording of information on the clients must follow a chronological order charting statements must be logically organized according to time and content.

Omissions

Blank spaces are not to be left on the chart and avoid writing outside the lines of the charting format.

Confidentiality

Information within the chart is often of a personal matter as well as legal evidence of the care provided and should be available for the necessary health team members only.

Standard

Spell correctly

Use proper grammar.

Put signature.

·           Affix signature, place at the end of charting at the right hand margin of the nurses notes.

·           Sign each entry with your full name and status, e.g. SN for Student Nurse, RN for registered nurse.

All due Medicines are given to Mr.Govind at 8pm by G.Stella

(Mrs.G.STELLA,RN) Registered Nurse

Bed bath given to Mrs. Sivagami at 6 am by R.Grace

( MISS.R.GRACE,SN) Student Nurse

·           In case of error.

§   Correct errors by drawing a single horizontal line through the error

§   Write the word error above the line, then sign your signature

§   No ink eradication, erasers or use of occlusive materials


 

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11th Nursing : Chapter 13 : Documentation : Principles of Nursing Documentation |


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