Note: This guideline is currently under review. Show
Aim Definition of Terms Process Assess Plan Implement and Evaluate Companion Documents Evidence Table References IntroductionNursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. AimTo provide a structured and standardised approach to nursing documentation for inpatients. This will ensure consistent clinical communication processes across the RCH. Definition of Terms
ProcessNursing documentation is aligned with the ‘nursing process’ and reflects the principles of assessment, planning, implementation and evaluation. It is continuous and nursing documentation should reflect this. Fig 1. Nursing Process
AssessAt the beginning of each shift, a ‘shift assessment’ is completed as outlined in the Nursing Assessment Guideline. The information for this assessment is gathered from handover, patient introductions, required documentation (safety checks and risk assessments, clinical observations) and an EMR review and is documented in relevant the ‘Flowsheets’. Review of the EMR gives an overview of the patient. To complete an EMR review, enter the patients’ medical record and work through the key activities in order. These tabs
can be customised to meet the specific needs of your patient group (EMR tip sheet link - coming soon). It is recommended that each ward standardises the layout of their activity bar based on their patient population.
Patient assessments are documented in the relevant flowsheets and must include the minimum ‘required documentation’. To ensure required documentation for each patient is complete, use the summary side bar link (EMR Req Doc tip sheet link -- coming soon). PlanWith the information gathered from the start of shift assessment, the plan of care can be developed in collaboration with the patient and family/carers to ensure clear expectations of care. The nursing hub is a shift planning tool and provides a timeline view of the plan of care including, ongoing assessments, diagnostic tests, appointments, scheduled medications, procedures and tasks. The orders will populate the hub and nurses can document directly from the hub into Flowsheets in real-time. Orders are visible by the multidisciplinary team. Management of orders is crucial to the set up and useability of the hub. It must be ‘cleaned up’ before handover takes place - too many outstanding orders is a risk to patient safety. Additional tasks can be added to the hub by nurses as reminders. All patient documentation can be entered into Flowsheets (observations, fluid balance, LDA assessment) throughout the shift. Clinical information that is not recorded within flowsheets and any changes to the plan of care is documented as a real time progress note. This may include:
Implement and evaluateProgress note entries should not simply list tasks or events but provide information about what occurred, consider why and include details of the impact, outcome and plan for the patient and family. All entries should be accurate and relevant to the individual patient - non-specific information such as ‘ongoing management’ is not useful. Example of real time progress note entry: Companion Documents
Evidence TableThe evidence table for this guideline can be viewed here. References
Please remember to read the disclaimer. The development of this nursing guideline was coordinated by Natasha Beattie, RN Cockatoo & Lauren Burdett, CNS Platypus and approved by the Nursing Clinical Effectiveness Committee. Updated March 2019. Which documentation by the nurse best supports the pie charting system?Which documentation by the nurse best supports the PIE charting system? PIE charting includes the Problem, Intervention, and Evaluation. The only entry that follows PIE charting is vomiting 250 mL undigested food (Problem), antiemetic given (Intervention), no further vomiting (Evaluation).
When completing documentation on each patient the nurse recognizes that documentation serves what purposes?1. "The purpose of written documentation is to communicate pertinent data to the health-care team." 2. "The purpose of written documentation is to serve as a record of accountability for accreditation."
Which components should the nurse include when documenting a critical pathway?The nurse should include the client's problems, goals, and nursing orders; routine care; level of activity; and current medical orders in the client's plan of care, as this information contributes to the nursing care plan.
Which strategy would provide the most effective form of change of shift report?Which strategy would provide the most effective form of change of shift report? Utilizing a reporting form and allowing time for any questions.
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