NUR 1311

THEORY, ETHICS &

PROFESSIONALISM IN
NURSING
Learning Outcomes
 By the end of the session student must be able to :
 Define individual record.
 Define care prescriber.
 State the rationale for documentation.
 Explain the general guidelines for nursing
documentation.
 Appreciate the knowledge of nursing
documentation in nursing.
Introduction.
 Documentation is any written or
electronically generated information
about a client that describes the care or
service provided to that client.

 Health records may be paper documents

or electronic documents, such as
electronic medical records, faxes, e-
mails, audio or video tapes and images.
 Through documentation, nurses communicate
their observations, decisions, actions and
outcomes of these actions for clients.
 Documentation is an accurate account of what
occurred and when it occurred.
 Nurses may document information pertaining
to individual clients or groups of clients.
 When caring for an individual client (which
may include the client’s family), the nurse’s
documentation provides a clear picture of the
status of the client, the actions of the nurse,
and the client outcomes.
REASONS FOR DOCUMENTATION
1. To facilitate communication.
➢Through documentation, 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.
➢Documentation of this information increases
the likelihood that the client will receive
consistent and informed care or service.
➢Thorough, accurate documentation
decreases the potential for
miscommunication and errors.
➢While documentation is most often done by
nurses and care providers,
➢there are situations where the client and
family may document observations or care.
➢ provided in order to communicate this
information with members of the health
care team.
2. To promote good nursing care.
➢Documentation 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.
➢Documentation can be a valuable source
of data for making decisions about
funding and resource management as well
as facilitating nursing research.
➢To improve the quality of nursing
practice and client care.

➢Individual nurses can use outcome

information or information from a
critical incident to reflect on their
practice and make needed changes
based on evidence.
3. To meet professional and legal standards
➢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
➢In a court of law, the client’s health
record serves as the legal record of the
care or service provided.

➢Nursing care and the documentation

of that care will be measured according
to the standard of a reasonable and
prudent nurse with similar education
and experience in a similar situation.
TOOLS FOR DOCUMENTATION
 There are many tools used for client
documentation, including worksheets
and kardexes, client care plans, flow
sheets and checklists, care maps,
clinical pathways and monitoring
strips.
Worksheets and kardexes.
 Nurses use worksheets to organize the
care they provide, and to manage their
time and multiple priorities.
 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 (College of Nurses
of Ontario, 2002).
 If a paper format is used, entries may
be erasable as long as the assessment,
nursing interventions carried out and
the impact of these interventions on
client outcomes are documented in
the permanent health record.

 When the kardexes is the only

documentation of the client’s care
plan, it is kept as part of the
permanent record.
Client care plans.
 Care plans are outlines of care for
individual clients and make up part of
the permanent health record.

 Care plans are written in ink (unless

electronic), up-to-date and clearly
identify the needs and wishes of the
client.
 Flow sheets and checklists.
 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).
 Flow sheets and checklists are part of the
permanent health record, and can be used
as evidence in legal proceedings (College
of Nurses of Ontario, 2002).
 Symbols (e.g., check marks) may be
used on flow sheets or checklists as
long as it is clear who performed the
assessment or intervention and the
meaning of each of the symbols is
identified in agency policy.
Care maps and clinical pathways
 Care maps and clinical pathways outline what care
will be done and what outcomes are expected over a
specified time frame for a “usual” client within a case
type or grouping.
 Nurses individualize care maps and clinical
pathways to meet clients’ specific needs (e.g., by
making changes to items that are not appropriate).

 If the status of clients varies from that outlined on

the care map or clinical pathway at a particular time
period, the variance documented, including the
reasons and action plan to address it.
Monitoring strips.
 Monitoring strips (e.g., cardiac, fetal or
thermal monitoring; blood pressure
testing) provide important assessment
data and are included as part of the
permanent health record.
 Documentation Methods.
 Most methods of documentation fall into one of
two categories:
1. Documentation by inclusion.
2. Documentation by exception (Coleman, 1997).
 Documentation by inclusion is done on an
ongoing, regular basis and makes note of all
assessment findings, nursing interventions
and client outcomes.
 Documentation by exception
 Regardless of the method used, nurses
are responsible and accountable for
documenting client assessments,
interventions carried out, and the
impact of the interventions on client
outcomes.
 Clients who are very ill, considered high
risk, or have complex health problems
generally require more comprehensive,
in-depth and frequent documentation.
 Three common documentation
methods
1. FOCUS CHARTING
 With this method of documentation, the nurse
identifies a “focus” based on client concerns or
behaviours determined during the assessment.
For example, a focus could reflect:
 The assessment of client status, the
interventions carried out and the impact of the
interventions on client outcomes are organized
under the headings of data, action and
response.
 Data: Subjective and/or objective
information that supports the stated focus
or describes the client status at the time of
a significant event or intervention.

 Action: Completed or planned nursing

interventions based on the nurse’s
assessment of the client’s status.

 Response: Description of the impact of

the interventions on client outcomes.
 Flow sheets and checklists are
frequently used as an adjunct to
document routine and ongoing
assessments.
 Observations such as personal care,
vital signs, intake and output, etc.
 Information recorded on flow sheets or
checklists does not need to be repeated
in the progress notes.
Check list.
Flow sheet.
2. SOAP / SOAPIE ( R ) C H A R T I N G.
 SOAP/SOAPIER charting is a problem-
oriented approach to documentation
whereby the nurse identifies and lists
client problems;

 Documentation then follows according

to the identified problems.
 Documentation is generally organized
according to the following headings:

➢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?)
3. NARRATIVE CHARTING.
 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.
➢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?)
Example SOAP report
Use of Technology.
 The principles underlying documentation,
access, storage, retrieval and transmittal of
information remain the same as for a
traditional, paper-based system.
 These new ways of recording, delivering and
receiving client information, however, pose
significant challenges for nurses, particularly
with respect to confidentiality and security of
client information.
 It is important that nurses be supported by
agencies in resolving these issues through clear
policies and guidelines and ongoing education.
ELECTRONIC DOCUMENTATION
 Stored electronically, under strict
security.
 must be comprehensive, accurate,
timely, and clearly identify who
provided what care (College of Nurses
of Ontario, 2002).
 Considered a permanent part of the
record and may not be deleted.
Expected Outcomes
Nursing Assessment
 The admission assessment should be
completed on the day of admission.
 Identified health problems should be
reviewed on a regular and timely basis.
 When the problem is resolved, it
should be noted.
 Normal & abnormal findings should be
included in reports.
Diagnostic Reasoning
Health needs, strengths, and
problems identified during nursing
assessment
Should be updated to reflect
changes
Planning
Nursing interventions developed to
address the person’s health needs
or problems.
Implementation
 Consistent with the nursing plan
 Include information about the status of
the health situation or problem, the
treatment rendered, and the person’s
response to treatment.
 Medication Administration Records
(MARs) should be completed at the
time medications are given and
treatments are completed
Evaluation
 Reflect the need to continue and/or
change the plan of care.
 Reflect changes in the nursing plan of
care.
 Include information about contacts with
prescribers and other members of the
interdisciplinary team
GENERAL GUIDELINES
When to chart?
 As soon after they occur as possible.
(ASAP).

Never document medications or

treatments before they are given
or completed.
What to chart?
 Symptoms: Use the person’s own
words, communication gestures, or
non-verbal cues as much as possible.

 Your observations: Failure to document

leaves gaps in the record that can be
interpreted as neglect.
What to chart?
 All injuries, illnesses and unusual health
situations until they are resolved.

 All contacts with the care prescriber:

➢Document what occurred:
 the chart was reviewed.
 the individual was seen.
 if the individual was examined.
What to chart?
 By phone, document what was discussed
and results of the contact (e.g., no
orders given, observe).

 Document the plan for follow-up.

 Response to a medication or treatment:

➢This includes therapeutic effects as well
as side effects.
 What to chart?
 All appointments and consultations:
 Name of consultant and specialty.
 Reason for consultation.
 Brief report of findings if available--if not, say so.
 If the consultation report is filed in the chart, the
nursing note may refer the reader to the
consultation report.
 If includes follow-up plans, the nursing note may
refer the reader to the consultation report.
 The person’s response to appointment.
What to chart?
 New symptoms or conditions.
 Each of the following should be
documented in the nursing notes at the
time of occurrence along with nursing
action taken and the person’s response:
 What to chart?
Abrasions, cuts, pressure marks
Falls and bumps, with or without apparent injury
Elevated temperature
Pressure ulcers including description and treatment until resolved
Rectal checks for constipation including findings and treatment
Seizures with complete description and treatment, if any
Possible adverse reactions to food or medicine
Refusal of meals or medications
Vomiting including type, amount, and treatment
STAT medications including time order is received and time medication is given
Unusual behavior or condition of the individual
Diarrhea or any change in bowel pattern
Any significant increase or decrease in weight
Changes or unusual difficulty in obtaining vital signs
What to chart?
Do NOT chart actions
completed by others.
How to chart?
 Date and time each entry.
 Do not leave blank lines between
entries. Draw a line through unused
spaces before and after your signature.
 Use only abbreviations and symbols
approved in agency policies.
 The use of slang, or labels should be
avoided unless used in the context of a
direct quote.
 How to chart?
 Interpretations of data should be supported by
descriptions of specific observations.
 Documentation should be clear, concise, and
specific.
 Don't use vague terms.
 Generalizations such as “good”, “fair”,
“moderate”, and “normal” should be avoided.
 Findings should be as descriptive as possible
including specific information about the
appearance or findings related to size, shape,
and amount.
How to chart?
 Correcting errors:
 Draw one straight line through the
incorrect entry.
 Initial and date the correction.
 Never use white-out(liquid paper),
erase, or eradicate an entry in the
individual’s record.
How to chart?
 Late entries: If you forget to chart something, it
may be entered into the record at a later time
but you must clearly state the date and time the
entry is being made and the date and time the
care or observations actually occurred.
 All entries in the nursing notes should be
signed. The signature should include the first
initial, last name and title (e.g., Siti, RN).
 A record of initials and signatures should be
maintained according to facility policy.
Do’s
Make sure your
Check that you have the documentation reflects
correct chart before you the nursing process and Write legibly.
begin writing. your professional
capabilities.

Chart the time you gave a Record each phone call to

Chart precautions or
medication, the a physician, including the
preventive measures used,
administration route, and exact time, message, and
such as bed rails.
the patient's response. response.

Chart patient care at the Document often enough to

time you provide it. tell the whole story.
 Don’ts
Don't chart a symptom, such as "c/o pain," without also charting
action taken.

Don't alter a patient's record - this is a criminal offense.

Don't use shorthand or abbreviations that aren't widely

accepted.

Don't write imprecise descriptions, such as "bed soaked" or

"a large amount."

Don't chart care ahead of time - may be unable to actually give the care
you've charted. Charting care that you haven't done is considered fraud.
Conclusion :RATIONALE FOR
DOCUMENTATION
Facilitates communication

Provides information

Data for quality assurance and

peer review programs.

Reimbursement from third-party

payers (i.e., Medicaid, Medicare)

Legal document