Examples & Functions of Nursing Documentation

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“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.

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