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Examples & Functions of Nursing Documentation

“If You Didn’t Write It Down, You Didn’t Do It”

This old nursing adage, applicable to all nursing documentation examples, has to be one of the oldest and most frequently used teaching tools in nursing education, yet it remains as valid today as it was a century ago. According to an article by Nikki Campos, “The Legalities of Nursing Documentation,” published on Lippincott’s online NursingCenter.com, “the objective of any state’s nursing practice, act as it pertains to documentation is the same across the country: to provide a clear and accurate picture of the patient while under the care of the healthcare team.” Communication to other healthcare providers is the first function of nursing documentation, always with an eye toward the goal of meeting and documenting standards in patient care.

Examples of Nursing Documentation

Even as nursing documentation transitions from written records to Electronic Health Records (EHRs), the types of routine nursing documentation remain the same. The most common types of nursing documentation include the following:

Nursing Progress Notes

Nursing progress notes are one of the most frequent and time consuming of nursing documentation tasks. In addition to the historical narrative notes, several other systems have been devised over the years to save time, improve documentation and standardized nursing notes. Types of progress note documentation systems include:

Narrative Nursing Notes

  • Traditional
  • Time-consuming
  • Inconsistent quality demonstrated
  • Used in typical “source records” hospital charts with information organized by information sources

Problem-Oriented Nursing Notes

  • Also referred to as Problem-Oriented Medical Records or “POMR”
  • Data is ideally organized by diagnosis
  • All members of the healthcare team utilize the progress note section
  • POMR notes typically use one of a number of organizational styles of writing progress notes:
    • SOAP or SOAPIE Notes
      • (S) Patient’s subjective complaint
      • (O) Objective findings
      • (A) Assessment findings
      • (P) Nursing or medical plan
      • (I) Intervention
      • (E) Evaluation of effectiveness
    • PIE Charting
    • (P) The problem as identified
    • (I) A planned intervention
    • (E) An evaluation of the efficacy of the intervention
    • (D) Objective data documenting problem
    • (A) Action or intervention planned
    • (R) Patient response to intervention conducted
    • DAR Focus Charting

Charting By Exception Nursing Notes

  • Used primarily in long-term care facilities
  • Decreases burden of frequent documentation of a primarily unchanging condition
  • Saves time and decreases the size of medical record
  • Assumes all standards are met unless otherwise noted
  • Exceptions require documentation

Nursing Admission Assessment

Nursing admission assessments are multipage forms that document a patient’s current condition, previous medical history, allergies, prescription drugs and primary complaint at the time of his or her admission to the hospital. The information is collected through an interview conducted with the patient and/or family and via a careful physical examination by the admitting nurse. The information and data garnered during a nursing admission assessment forms the basis of the nursing care plan. Some facilities have different admission assessments utilized for the different types of care provided. For instance, a patient may require an Emergency Department (ED) Nursing Admission Assessment followed by an Intensive Care Unit (ICU) Admission Assessment completed upon transfer. When the patient improves enough to be transferred to the general medical population, he or she will often have another nursing admission assessment completed to reflect the new goals for the patient’s improved condition.

Nursing Care Plans

Nursing care plans are the organized means by which patient problems (nursing diagnoses) are identified, and nursing interventions prescribed to address the patient’s physical, mental, social, psychological or educational needs. Characteristics of these documents include:

  • Standardized plans of care based upon disease or nursing diagnosis
  • Modification of the care plans based upon the patient’s individual needs
  • Promotes improved and standardized means of patient care
  • Ensures treatment based on the same minimum level of knowledge among all healthcare providers

Graphic Sheets

Graphic sheets refer to charts and graph that aid in documenting objective physical measurements required during patient care. These include:

  • Vital Signs Graphics
    • Allows graphing of patient pulse, blood pressure, temperature and respiratory rate on a single multidimensional graph
    • Provides an area for recording patient weight
  • Intake/Output Record (I & O)
  • Allows staff to record patient fluid intake by mouth or intravenously to be totaled at the end of each shift and each day
  • Allows staff to record patient fluid output by urinary catheter, nasogastric suction or urination into measured containers to be totaled at the end of each shift and each day
  • The resulting sum allows staff to document fluid retention or hypovolemia

Medication Administration Records (MARs)

Whether hand-written, partially computerized or totally computerized, medical administration records (MARs) document what medications are prescribed to each patient, the dosage, the administration route, and the administration schedule. Each nurse “initials” or indicates administration of each medication as provided to his or her assigned patients. MARs are reviewed prior to each nursing shift to ensure that any medication changes have been properly recorded.

Nursing Scholarships

American Assembly for Men in Nursing (AAMN) American Cancer Society Doctoral Degree Scholarships in Cancer Nursing Gallagher Student Health Careers Scholarship
The Gates Millenium Scholars (GMS) National Black Nurses Association (NBNA) National Student Nurses’ Association (NSNA)
New Careers in Nursing (NCIN) Nurse Corps Scholarship (NCS) Nurses of Tomorrow
Nursing Economics Foundation Tylenol Future Care Scholarship American Holistic Nurses Association

Grand Canyon University

Nursing Degree Programs from Grand Canyon University's College of Nursing & Health Care Professions

Programs:

  • M.S. in Nursing: Nursing Leadership in Health Care Systems
  • Ed. D. in Organizational Leadership with an Emphasis in Health Care Administration
  • M.S. in Health Care Administration
  • And more...

South University

Several nursing programs are available at the bachelor's, post-graduate, master's, and doctoral levels.

Programs:

  • Healthcare Management (BS)
  • Nursing (BS)

Colorado Technical University Online

A degree from CTU connects you to what matters most: powerful professional network, real-world professional faculty and innovative technology. Once you earn your degree you hit the ground running.

Programs:

  • Master of Science in Management - Healthcare Management
  • Master of Science in Healthcare Management - Informatics
  • Doctor of Management - Healthcare Management and Leadership (Executive Format)
  • And more...

South University, Online Programs

As a student at South University, Online Programs, you will receive the same quality instruction, variety of learning options and level of service found at the campus locations.

Programs:

  • Specialization in Nurse Administrator (MSN)
  • Healthcare Administration (MBA)
  • Healthcare Management (BS)
  • And more...

Kaplan University

Kaplan University is focused on recognizing the achievements of military and veteran students and offers the flexibility of an online education.

Programs:

  • MS in Nursing - Executive Leader
  • Medical Office Administration
  • Master of Health Care Administration
  • And more...

American InterContinental University Online

With your busy schedule and the desire to move your career forward, you can earn an accredited associate, bachelors or master’s degree at a pace that works for you anywhere, anytime, 24/7.

Programs:

  • Master's – Healthcare Management

Liberty University

Liberty University provides a world-class education with a solid Christian foundation, equipping men and women with the values, knowledge, and skills essential for success in every aspect of life.

Programs:

  • MS in Exercise Science: Nutrition
  • MS in Exercise Science: Community Physical Activity
  • Master of Science: Healthcare Administration
  • And more...

Milken Institute School of Public Health at the George Washington University

Located in the heart of Washington, D.C. the Milken Institute School of Public Health at the George Washington University is dedicated to advancing the health of local, national and global communities.

You need to have a Bachelor’s degree to be qualified for this school.

Programs:

  • Executive Master of Health Administration

Medical Careers Institute

Start a great career in healthcare with Medical Careers Institute.

Programs:

  • Healthcare Administration - Bachelor's
  • Nursing (RN-BSN) - Bachelor's

Southern New Hampshire University

Give your career a boost with an education from Southern New Hampshire University.

Programs:

  • MS Management - Healthcare
  • BS Healthcare Administration
  • Master of Science in Healthcare Administration
  • And more...

Platt College

Turn your talents into a career at nationally recognized and accredited Platt College.

Programs:

  • Healthcare Management

Northcentral University

Earn your graduate degree online with Northcentral University.

Programs:

  • Doctor of Education - Nursing Education

Grantham University

Grantham University's 100% accredited online degrees are convenient, portable and designed so you can fit education into your life instead of arranging life around your education.

Programs:

  • Master of Science in Health Systems Management
  • Bachelor of Science in Health Systems Management
  • Master of Healthcare Administration

Milken Institute School of Public Health at the George Washington University

Located in the heart of Washington, D.C. the Milken Institute School of Public Health at the George Washington University is dedicated to advancing the health of local, national and global communities.

You need to have a Bachelor’s degree to be qualified for this school.

Programs:

  • Executive Master of Health Administration

Fortis Institute

At Fortis Institute, you may get the skills and training you need to prepare for a career.

* Programs vary by location

* Please contact each individual campus for accreditation information


Programs:

  • Associate Degree in Nursing

South University

As a student at South University, you will have the opportunity to learn from accomplished faculty members who have real-world experience in the subjects that they teach. Our small class sizes allow you to receive personalized attention from instructors, and the encouragement to recognize your goals for the future and the means to achieve them.

Programs:

  • Healthcare Management (BS)
  • Nursing (BS)

Centura College

Centura College, with campus locations in Virginia, South Carolina and Florida.

Programs:

  • Practical Nursing Diploma

Keiser University Graduate School

For over 35 years, Keiser University has maintained a practical, hands-on approach to career education to help our students achieve their personal and professional goals. 

Programs:

  • Master of Science in Nursing

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