Question

12)   Briefly describe the following principles underpinning nursing documentation (in 30-50 words each).

12.1)   Factual:

12.2)   Accurate and complete:

12.3)   Current (timely):

12.4)   Organised:

Answer 1

12. principles if nursing documentation

12.1 factual

• factual means the document should have fact.
• aunthenticated data should provided in documentation.
• should avoid use of vague words like appears, seems, may be.
• it should have objective and subjective data with reference.
• for example the the patient having abnormal vital sign is a factless data. it should present as the vital sign of patient is temperature 101^o F, pulse 76b/m,respiration 30b/m and so on.
• factual data is also essential to maintain during documentation to prevent manupulation and illegal presentation of data.

12.2 accurate & complete

• the data should accurate and complete to prevent misleading of care.
• use exact data or measurement like intake is 450ml/24hr.
• in each pagee of patient should havee name, age, sex, UHID Aaccurately.
• if accurate and complete data not provided then there is chance of duplication of care.
• only approved abbreviation shoulh use over documentation.
• for example in medication chart if drug is given but no sign in chart, so there is chance of repetation of drug.
• if any thing prescribed by the doctor that should accurately mention over the nurses note.
• abbreviation like pt. or any unapproved abbreviation should avoided and avoid using of shortforms.

12.3 current (timely)

• the documentation should donr timely.
• for example writing over nurses note is a ongoing process.if we start writing at the end of shift it will create many problems. we may forget the procedure what we did, may forget the actual data or assessmeent record also.
• if any thing prescribed or any drug changed by the doctor that should immediate noted and implemented.
• recording the data timely manner like 6am, 7am or according to 24hr.
• dont put the time advancely.

12.4 organised

• the data documented should organised properly like numerically or alphabatically.
• in nurses note we should put the note by using serial no.
• in any note the data should present by using SOP (subjective data, objective data, planning) manner.
• the file should have the documents in organised way and avoid spelling mistake also.