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Gama Hospital

Al Khobar K.S.A

NICU Documentation

DEFINITION:

Nursing documentation is a process in which clinical observation related to patient’s


health status, response to interventions by nursing and other health care professional and
evaluation of outcomes are identified and recorded in the medical record.

GOAL:

To provide professional responsibility, communication, legal and practice standards,


educational research, auditing and accountability to the client, the institution and to all
health care practitioners.

OBJECTIVES:

1. To establish a standard for documentation of patient’s progress within GAMA


Hospital
2. Provide a standardized method to communicate pertinent data to nurses and other
health care professionals.
3. To provide a uniform approach in dealing with patients nursing problems/needs.
4. To provide guidelines to assist the nurse in documenting patient’s response to
therapeutic interventions.

I. Nursing Policy on Documentation

Nursing documentation is a process in which the patient’s experience from admission to


discharge is recorded in a manner which enables all clinical staff involved in the patient’s
care to detect changes in the patient’s condition and the patient’s response to treatment
and care delivery. This allows treating teams to make decisions about the best treatment
options for the patient based on accurate, objective and current information.

The minimum standard for Nursing Documentation challenges nurses and to focus on
their patients when they are documenting nursing care. It requires the nurse to document
the patient experience from the patient’s point of view, rather than writing from a
position that either favors the nurse or the institution. The resulting objective assessment
describes how the patient views their reason for admission, their response to care and
other interventions as well as any other information that the patient relates to the nurse.
All nurses in Gama Hospital shall use the standardized guidelines that the hospital
provides to document nursing practice.

II. NICU/NURSERY Documentation Forms

 NICU/Nursery Kardex

A Kardex is a medical information system used by nursing staff as a way to communicate


important information on their patients. It is a quick summary of individual patient needs
that is updated at every shift change. It is used to communicate current orders, upcoming
tests or surgeries, special diets or the use of aids for independent living specific to an
individual client. 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 kardex is the
only documentation of the client’s care plan, it is kept as part of the permanent record.

 Nurses Progress Notes

A Nurses Progress notes is an ongoing record of a patient’s illness and treatment


from the time of admission until the time of discharge. These notes describes the
patient’s condition, treatment plan and given and the outcome. It usually focuses
on the objectives stated in a nursing care plan. These objectives may include
responses to prescribed treatments, routine new born care being rendered,
necessary investigations being done and the evaluation of the total management of
the patient.

 Pediatric and Newborn Special Care Flow Sheet

The Special Care Flow Sheet is being used in replacement to the Nurse Progress
Notes if the newborn is admitted in NICU demanding close monitoring or in
critical state. It is a complete monitoring sheet that includes a thorough TPR
record with ventilator settings, blood extraction record, hourly input and output
monitoring, VBG and electrolytes charting, weight charting, urine test charting,
nursing care check list etc.

 24 Hours Fluid Balance Chart

A 24 hour record used to monitor input and output of fluids. Input includes oral fluids
and infused intravenous fluids and blood products. Output includes fluid loss as urine,
emesis, and wound drainage. 

 T. P. R. Chart

TPR stands for Temperature, Pulse Rate and Respiratory Rate. It is used to record
the temperature, pulse rate and respiratory rate of the patient.

 Medication Administration Record


Medication Administration Record serves as a legal record of the drugs administered to
a patient. It is a part of a patient's permanent record on their medical chart. The nurse
signs off on the record at the time that the drug is administered.

 Laboratory and X-ray Mount Sheet

This serves as a form where the nurse can attach the laboratory and x-ray results.

 Immunization Record

Immunization Record is used to document the vaccines given to the newborn at a


certain month and age.

III. Nursing Process: APIE

Nursing Process is a deliberate problem solving approach for meeting a person’s


health care needs. It is categorized into four steps:

a. Assessment – collection of data about a client, family or group. The nurse


obtains data by interview, observation and examination.
b. Planning – formulation of nursing diagnosis that based on the data
gathered. When there are multiple nursing diagnosis to be addressed, the
nurse prioritizes which diagnosis will receive the most attention first
according to their severity and potential for causing more serious harm.
c. Implementation – The nurse implements the nursing care plan, performing
the determined interventions that were selected to help meet the
goals/outcomes that were established. Delegated tasks and the monitoring
are included here as well.
d. Evaluation – an evaluation of the patient’s response to the interventions
done is made and documented. The process repeats again if the goal is not
met or there are new problems that have surfaced.

IV. Guidelines in Documentation

 The professional nurse will document clinical observations, problems,


interventions and response to treatment on appropriate forms.
 Frequency of documentation narrative/interdisciplinary progress note is based on
change in the status of the patient and/or identified in general or specialty manual
standards.
 When a nurses’ full signature is required, entries should be written in the
following manner: first initial, family name, credentials and badge number (ex.
W.Panopio RN 3756) if name stamp is not available, your name should be clearly
printed above or below your signature.
 Some designated areas of nursing flow sheet require only the initials of the nurse
and badge number. (ex. W.P. 3756)
 If it is not documented, it is not done.
 Documentation should be accurate, brief and complete.
 Check for the right chart with the right patient.
 There shall be documentation of assessment, intervention and evaluation for each
hospitalized patient from admission through discharge.
 Read the previous nurses notes.
 Plan of care shall be documented and reflect current standards of nursing practice.
 Documentation of nursing care shall be pertinent, concise, reflect patient’s status
and address the patient’s needs, problems, capabilities and limitations with
nursing intervention and patient response noted.
 Standardized documentation of routine elements of care and repeated monitoring
of personal hygiene, administration of medication and physiologic parameters.
 When a patient is transferred within or discharged from the hospital, the patient’s
status should be documented in the medical records.
 Evidence of the instructions shall be documented in patient’s medical record.
 Place patient’s name and ID number on each sheet of medical record.
 Documentation should be neat and legible by pen.
 Don’t chart in advance, don’t wait to chart and don’t chart for anyone else.
 Don’t falsify records.
 Use flow sheets where appropriate.
 Don’t skip lines between entries and don’t leave space before your signature.
 Correcting document errors: if a note is written out of chronological sequence
(late entry) the nurse must insert “see note” (date/time) in the margin or other
empty space where the note should have been written. Move to the bottom of the
most recent entry. Write the present date, time, place an asterisk (*) and write
“Late Entry” and the date and time the entry should have been written. Then,
continue with documentation.

Example entry out of chronological order:

15/06/2008 1400h Temperature 39.4 degrees C, Dr. Mostafa notified blood


culture x3, urine and wound culture to laboratory. W.Panopio 3756
15/06/2008 2000h Tearful due to migraine. Medicated with Demerol 50mg IM
as ordered by Dr. Mostafa. W.Panopio 3756
15/06/2008 2145h Resting quietly. W.Panopio 3756
15/06/2008 2245h *Late entry from 15/06/2008 1600h, patient found on the
floor in the bathroom. Alert, no apparent injury. Denies pain, stated she became
dizzy while returning to bed and slipped on the floor. Assisted back to bed, and
instructed to remain in bed until seen by physician, Dr. Jones notified. W.
Panopio 3756

 If the entry is incorrect, draw a single line through it. Note “error” and sign the
entry with your initials and badge number and the date and time of entry. A one or
two word correction can be written above the line out of entry if there is space. If
there is no space or the correction is longer than a word or two, insert an asterisk
(*) beside the word and enter the correction as late entry.
 Do not write an entry for another nurse and sign it as your own. If the nurse calls
in to report an omitted entry, note the date and time, the nurse name and badge
number and the information received. Sign your name and badge number of the
nurse who called in the information and is responsible for co signing the entry by
the end of the next duty shift.

Example entry made for another nurse:

20/01/2008 1800h S. Dee RN 3040. Reported patient was medicated with


Demerol 50mg at 1430h today for moderate incisional pain. S.Dee RN 3040

 Each documentation entry must be legible, dated and timed in permanent blue or
black ink.
 Timed entries are identified using 24 hours time format.
 Only standard hospital abbreviations approved by the Medical Records
Committee are to be used.
 No erasures, no ditto marks, white out and sticky labels are permitted on the chart.
Leave no blank lines. Mark through a blank space between the text that was
written and the nurses’ name.

Resources:

 http://www.cbahi.org/rm/files/Standards/NR/Teaching%20Tools/41%20NR
%20Nursing%20Documentation.pdf
 http://study.com/academy/lesson/what-is-kardex-definition-use-in-nursing.html
 http://www.conursing.uobaghdad.edu.iq/uploads/others/d.ali%20d/Nursing
%20Documentation.pdf
 http://medical-dictionary.thefreedictionary.com/progress+notes
 http://medical-dictionary.thefreedictionary.com/Kardex
 http://medical-dictionary.thefreedictionary.com/fluid+balance+chart
 https://en.wikipedia.org/wiki/Medication_Administration_Record
 Gama Hospital General Procedure Manual
Prepared by:

Ms. Wella Joy G. Panopio


NICU/Nursery Staff Nurse

Reviewed and Approved by:

Ms. Virginia M. Lorda


Nursing Education Coordinator

Approved by:

Madame Faten Taha


Director of Nursing
Documentation in NICU

Ms. Wella Joy G. Panopio


NICU/Nursery Staff Nurse
April 2015