NURSING PROCESS/

DOCUMENTATION



THE NURSING PROCESS
Includes 5 steps:
1. Assessment
2. Diagnosis
3. Planning and outcome identification
4. Implementation
5. Evaluation
THE NURSING
PROCESS (continued)
A series of steps that lead to
accomplishing some goal or purpose.
A systematic method for providing
care to clients.
Provides individualized, holistic,
effective and efficient client care.
Clients of all ages and in any care
setting.
ASSESSMENT
The first step in the nursing process.
Includes systematic collection,
verification, organization,
interpretation, and documentation of
data.

THE PURPOSE
OF ASSESSMENT
To organize a database regarding a
clients physical, psychosocial, and
emotional health.
To identify health-promoting
behaviors and actual and/or potential
health problems.
TYPES OF ASSESSMENT
Comprehensiveprovides baseline
client data.
Focusedlimited to a particular
need or health care concern.
Ongoingincludes systematic
monitoring of specific problems.
SOURCES OF DATA
Primary sourceclient or the major
provider of information about a client.
Secondary sourcesources of data
other than client and include family
members, other health care providers,
and medical records.
TYPES OF DATA
Subjective datadata from clients
point of view, and include perceptions,
feelings, and concerns. Collected by
interview.
Objective dataobservable and
measurable, obtained through both
physical examination and the results
of lab and diagnostic testing.
VALIDATING THE DATA
Prevents misunderstandings,
omissions, and incorrect inferences
and conclusions.
ORGANIZING THE DATA
Data must be organized.
Data clustering is the process of
putting the data together in order
to identify areas of the clients
problems and strengths.

INTERPRETING THE DATA
Organizing data in clusters helps to
recognize patterns of response or
behavior:
Distinguish between relevant, irrelevant.
Determine whether and where there are
gaps in the data.
Identify patterns of cause and effect.
DOCUMENTING THE DATA
The nurse must decide which data
should be immediately reported and
which data can just be recorded.
It is essential for accurate and
complete recording of assessment
data to communicate information to
other health care team members.
DIAGNOSIS
Second step in the nursing process.
Clinical judgment about individual,
family, or community response to
actual or potential health
problems/life processes.
Provides the basis for client care
through the remaining steps.
MEDICAL DIAGNOSIS
Clients have both nursing and medical
diagnoses.
A medical diagnosis is a clinical
judgment by the physician that
identifies or determines a specific
disease, condition, or pathological
state.
TWO-PART
NURSING DIAGNOSIS
Part oneproblem statement or
diagnostic label describing the clients
response to actual or risk health
problem or wellness condition.
Part twoetiology or the related
cause or contributor to the problem.
Linked by the term related to (r/t).
THREE-PART
NURSING DIAGNOSIS
Part onediagnostic label.
Part twoetiology.
Part threedefining characteristics, or
signs and symptoms, subjective and
objective data, or clinical
manifestations.
Third part linked to the first two by
the term as evidenced by (AEB).
TYPES OF
NURSING DIAGNOSES
Actual nursing diagnosisindicates
that problem exists.
Risk nursing diagnosisindicates that
specific risk factors are present.
Wellness nursing diagnosisclients
statement of desire to attain a higher
level of wellness in some area of
function.
PLANNING AND
OUTCOME IDENTIFICATION
Third step of the nursing process.
Includes establishing guidelines for
the proposed course of nursing action
and developing the clients plan of
care.
PLANNING PHASES
Initial planningdeveloping a
preliminary plan of care.
Ongoing planningupdating the
clients plan of care.
Discharge planninganticipating and
planning for the clients needs after
discharge.
PLANNING INVOLVES
Prioritizing the nursing diagnoses.
Identifying and writing client-centered
long- and short-term goals and
outcomes.
Identifying specific nursing
interventions.
Recording the entire nursing care plan
in the clients record.
NURSING INTERVENTIONS
Actions performed by nurse to help
client achieve results specified by
goals and expected outcomes.
Refer directly to the related factors or
the risk factors in nursing diagnoses.
Are stated in specific terms.
May change.
CATEGORIES OF
NURSING INTERVENTIONS
Independentinitiated by the nurse
and
do not require an order.
Interdependentimplemented in a
collaborative manner by nurse in
conjunction with other health care
professionals.
Dependentrequires an order.
THE NURSING CARE PLAN
Written guide of strategies to be
implemented to help client achieve
optimal health.
Begins on the day of admission and
continues until discharge.

IMPLEMENTATION
Fourth step in the nursing process.
The performance of the nursing
interventions identified during the
planning phase.
ORDERS FOR INTERVENTIONS
Specific orderfor individual client.
Standing orderstandardized
intervention written, approved, and
signed by a physician, kept on file to
be used in predictable situations.
Protocolseries of standing orders or
procedures.
EVALUATION
Fifth step in the nursing process.
Determines whether client goals have
been met, partially met, or not met.
Ongoing evaluation is essential for the
nursing process to be implemented
appropriately.

THE NURSING PROCESS
AND CRITICAL THINKING
Critical thinkers ask questions,
identify assumptions, evaluate
evidence, examine alternatives, and
seek to understand various points of
view.
Critical thinking can be learned.
DOCUMENTATION
Any printed or written record of
activities.
Recording and reporting are the
major ways health care providers
communicate.
The clients medical record is a legal
document of all activities regarding
client care.
PURPOSES OF DOCUMENTATION
Communication
Practice and legal standards
Reimbursement
Education
Research
Nursing audit
COMMUNICATION
Documentation confirms the care
provided to the client and clearly
outlines all important information
regarding the client.
PRACTICE AND
LEGAL STANDARDS
The legal aspects of documentation
require:
Writing legible and neat
Spelling and grammar properly used
Authorized abbreviations used
Time-sequenced factual and
descriptive entries
PRACTICE
STANDARDS INCLUDE:
State Nursing Practice Acts
Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)
Confidentiality
Informed consent
Advance Directives
REIMBURSEMENT
The federal government requires
monitoring and evaluation of quality,
appropriateness of care provided.
Documentation of intensity of services
and severity of illness reviewed.
Failure to document can result in
reimbursement denied.
EDUCATION
Health care students use medical
record as tool to learn about disease
processes, nursing diagnoses,
complications and interventions.
Students can enhance critical-thinking
skills by examining the records and
following health care teams plan of
care.
RESEARCH
The clients medical record is used by
researchers to determine whether a
client meets the research criteria for
a study.
Documentation can also indicate a
need for research.
NURSING AUDIT
Method of evaluating the quality of
care
Includes:
Safety measures
Treatment interventions and responses
Expected outcomes
Client teaching
Discharge planning
Adequate staffing
PRINCIPLES OF EFFECTIVE
DOCUMENTATION
1. Document accurately, completely,
and objectively, including any errors.
2. Note date and time.
3. Use appropriate forms.
4. Identify the client.
5. Write in ink.
6. Use standard abbreviations.
PRINCIPLES OF EFFECTIVE
DOCUMENTATION (continued)
7. Spell correctly.
8. Write legibly.
9. Correct errors properly.
10.Write on every line.
11.Chart omissions.
12.Sign each entry.
SYSTEMS OF DOCUMENTATION
Narrative charting
Source-oriented
charting
Problem-oriented
charting
PIE charting

Focus charting
Charting by
exception
Computerized
documentation
Critical pathways
NARRATIVE CHARTING
Traditional method of nursing
documentation.
Chronologic account in paragraphs
describing client status, interventions
and treatments, and clients response.
The most flexible system.
Usable in any clinical setting.
SOURCE-ORIENTED CHARTING
Narrative recording by each
member of the health care team on
separate documents.
PROBLEM-ORIENTED CHARTING
SOAP, SOAPI, AND SOAPIER
S: subjective data
O: objective data
A: assessment data
P: plan
I: implementation
E: evaluation
R: revision
PIE CHARTING
P: problem
I: intervention
E: evaluation

FOCUS CHARTING
System using a column format to
chart Data, Action, and Response
(DAR).
CHARTING BY EXCEPTION
Only significant findings (exceptions)
are documented in a narrative form.
Presumes that unless documented
otherwise, all standardized protocols
have been met and no further
documentation is needed.
COMPUTERIZED DOCUMENTATION
Reduces time taken, increases
accuracy.
Increases legibility.
Stores, retrieves information quickly.
Improves communication among
health care departments.
Confidentiality and costs can be
problems.
CRITICAL PATHWAY
Also known as Care Maps.
Comprehensive pre-printed standard
plan reflecting ideal course of
treatment for diagnosis or procedure,
especially with relatively predictable
outcomes.
Additional forms are needed to
complement the pathway.

NURSES PROGRESS NOTES
Document clients condition,
problems, complaints, interventions,
and clients response to
interventions.
Include MAR, vital signs records, flow
sheets, and intake and output forms.
DISCHARGE SUMMARY
Client status on admission and
discharge
Brief summary of the clients care
Intervention and education outcomes
Resolved and unresolved problems
Client instructions about medications,
diet, food-drug interactions, activity,
treatments, follow-up, and other
needs
DOCUMENTATION TRENDS
Nursing Minimum Data Set (NMDS)
Nursing Diagnoses
Nursing Interventions Classification
(NIC)
Nursing Outcomes Classification
(NOC)
INFORMATION
FOR SHIFT REPORT
Name, room and
bed, age, gender
Physician,
admission date,
and diagnosis
Diagnostic tests or
treatments
performed in past
24 hours (results if
ready)
General status, any
significant change
New or changed
physicians orders
IV fluid amounts,
last PRN medication
Concerns about
client
TELEPHONE ORDERS
Date and time
Order as given by the physician
Signature beginning with t.o.
(telephone order)
Physicians name
Nurses signature
Physician must countersign