Search for school

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

EducationConnection

Start 2018 with steps toward earning your degree with Education Connection!

Programs:

  • Subject

Full Sail University - Online

Push Your Creativity To The Next Level

Programs:

  • Cloud Technologies Bachelors - Online
  • Graphic Design, Bachelor of Science (Online)
  • Entertainment Business, Master of Science (Online)
  • And more...

Purdue University Global

Ranked among the Best Online Bachelor's Programs in 2015 by U.S. News and World Report.

Programs:

  • BS in Business Administration
  • MS in Accounting - Audit Specialization
  • AAS in Criminal Justice
  • And more...

Kaplan University

Earlier this year, Purdue acquired Kaplan University and created a new public, nonprofit institution named Purdue University Global.

Programs:

  • BS in Business Administration - Project Management
  • MSHUS- Family and Community Services
  • AAS in Information Technology - Network Administration
  • And more...

The Art Institutes system of schools

With an education from an Art Institutes school, imagine what you could create.

Programs:

  • Visual Arts (BFA)
  • Fashion Retailing (D)
  • Culinary Management (BA)
  • And more...

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:

  • Bachelor of Science in Nursing (RN to BSN completion)
  • Master of Science in Information Technology - Network Management
  • Bachelor of Science in Criminal Justice – Human Services
  • And more...

Argosy University, Online Programs

Argosy University offers doctoral, master's, and bachelor's degree programs to students through its eight colleges.

Programs:

  • Business Administration (BS)
  • Curriculum and Instruction (EdD)
  • Liberal Arts (BA)
  • 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:

  • Nurse Educator (PGC)
  • Nursing (RN to BSN)
  • Specialization in Nursing Informatics (RN to MSN)
  • And more...

Full Sail University - Online

Learning at Full Sail University has always centered around interaction and the exchange of ideas. Our online curriculum fully embraces this philosophy.

Programs:

  • Cloud Technologies Bachelors - Online
  • Graphic Design, Bachelor of Science (Online)
  • Entertainment Business, Master of Science (Online)
  • And more...

Lincoln Tech

Get a hands-on, job-specific education at Lincoln Tech.

Programs:

  • Electrical/Electronics
  • Heating, Ventilation, & Air Conditioning (HVAC)
  • Automotive Technology

Centura College

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

Programs:

  • Associate of Occupational Science Degree in Medical Assisting-Concentration in Clinical Support
  • Health Information Technology
  • AOS Information Technology Specialist
  • And more...

Universal Technical Institute

At Universal Technical Institute (UTI), you won't just train for a career. You'll train for success. 

Programs:

  • Motorcycle

ECPI University

Making the decision to earn your degree and pursue your career goals could be the best decision you ever make. Enroll at ECPI University and you’ll join a collaborative and fostering learning environment, surrounded by faculty and staff who are there to support you through the entire process.

 

What Are You Waiting For?

Programs:

  • Cloud Computing - Bachelor's
  • Cyber and Network Security - Bachelor's
  • Network Security - Associate's
  • And more...

Culinary Institute of Virginia

Turn your passion for food into a career at the Culinary Institute of Virginia.

 

What Are You Waiting For?

Programs:

  • Baking and Pastry Arts
  • Culinary Arts

Aviation Institute of Maintenance

Aviation Institute of Maintenance schools are distinguished institutes committed to the education and personal enrichment of each student interested in the Aviation Industry.

Programs:

  • Aviation Maintenance Technician

CDS Tractor Trailer Training

Start your rewarding career in trucking at CDS Tractor Training School.

Programs:

  • Class "B" Training and Bus Training
  • Class "A" Training

The Art Institutes system of schools

With an education from an Art Institutes school, imagine what you could create.

Programs:

  • Fashion Retailing (C)
  • Culinary Management (BS)
  • Digital Image Management (C)
  • And more...

Salem University Online

Advance your career with a quality education from Salem University Online.

Programs:

  • BA Criminal Justice - Homeland Security
  • BSBA - Management
  • M. Ed. Instructional Technology
  • And more...

Related Post

How to Obtain a Career in Correctional Nursing

Choosing to become a corrections nurse is a decision that should not be taken lightly. A corrections nurse is responsible for attending to inmates at correctional facilities across the country.

Why Taking a NCLEX Refresher Course is Important

Every licensed nurse in the United States has gone through the grueling experience of taking the National Council Licensure Examination, or NCLEX, and most likely every nurse can verify that an NCLEX