Lecture By Rahima M Salendab Meeqat General hospital ,Madinah,KSA

2. the nursing profession involves legalities when in
comes to caring patients in all groups. These legal
issues can only straighten when there is accurate
DOCUMENTATION. The common term used in
the field of nursing when it comes to
documentation is CHARTING
The most integral part of the nurse’s responsibility is the
CHARTING FOR NURSES

3. Documentation- in nursing is a key factor in our role and
responsibility as a patient care advocates. It is critical for
determining if the standard of care was rendered to a patient
to defend prior nursing actions. Failure to chart, omissions,
and poor communication are hard to defend
Charting - the act of compiling data on clinical records
or charts (computerized or paper). The charts are
updated regularly to keep physicians and other health
care workers advised of changes in the patient's
condition. The data usually include fluctuations in
temperature, pulse, respiration, other variable factors,
and much more, including all nursing care.

6. Types of Documentation Systems
DATA : ACTION : RESULT
For example:
D
A
R
Patient fell
Staff picked him up, brushed him off and
reinforced teaching re using walker
Patient safely used walker rest of shift

8. Subjective Charting Sample
• Appears to be sleeping
• Angry
• Seems to be agitated

14. Be extra careful when you think you are "too busy."
Be aware of critical times such as:
 abnormal vital signs
 codes
 transfers
 change of nursing shift or patient hand
over (endorsement)
 taking verbal orders
 noting physician’s orders
 verifying medication orders
 date & time of each procedure

15. The nurse must report critical values to the physician within 30 minutes.

16. Avoid general statements.
Beware of general statements that can be
misconstrued . For example, you wrote
“Seen by ER doctor. ” “Seen by Surgeon”
Did you mean:
 Seen by Dr. Moh'd ali?
 Seen & Examine by surgeon
(Seen & examined by
Surgeon Dr. Adel).

17. Late entries and any corrections entered should be per policy and
procedure.

19. Charting patterns including flow sheets will be reviewed. “Too
perfect” charting may raise doubts. Patient assessment such as fall risk
or skin assessments, & new onset of pain must be carefully performed
and documented. Failing to do so is a common error

20. Consult the nursing policy and procedure for accepted abbreviations.
Sign each entry correctly, including date and time. An illegible signature
may lead to all nurses on duty being named in order to “cast a wide
net.” Date and time are crucial when creating a chronology of events.
SAMPLE NURSES NOTES
M.E
DATE TIME NURSES NOTES SIGNATURE
14/01/1440 07:30H
08:00H
08:15H
12:00H
14:00H
14:00H
14:00H
15:30H
- Received on bed, awake & responsive, with IV
cannula G22 at left arm, intact, with ongoing
IV Normal Saline 500 cc at the level of 250 cc,
infusing well.
- Seen & examined by Dr. Salah, Medical
Specialist with orders made & carried out.
- Blood for CBC, Biochem extracted, sent to
lab.
- Lunch served with fair appetite
- All medication given at due time
- Inj. Flagyl 500 mg given IV
- Tab. Adol 500 mg given P.O.
- All needs attended, no complaints made.
- Endorsed to next shift
- Fax send for CT abdomen to KFH
- "late entry" Abdominal ultra sound done at
10:00H, report seen by Dr. Salah at 10:30H.
R. Salendab
R. Salendab
R. Salendab
R. Salendab
R. Salendab
R. Salendab
R. Salendab
R. Salendab
Rahima Salendab
Rahima Salendab