Documentation & the Nursing Process: A Review

This handbook offers a thorough overview of nursing documentation, and its importance, within the context of the nursing process. Users learn the principles of effective documentation and methods of documenting and examine trends relevant to this aspect of nursing care. Example forms are included to provide readers with hands-on experience with the documentation format.

Preface

ix

Organization

ix

Features

x

Acknowledgments

xi

About the Author

xi

Reviewers

xii

UNIT 1 NURSING PROCESS

1

(70)

Nursing Process

3

(12)

Introduction

3

(1)

Historical Perspective

4

(1)

Overview of the Nursing Process

5

(1)

The Nursing Process and Critical Thinking

6

(3)

The Nursing Process and Problem Solving

9

(1)

The Nursing Process and Decision Making

9

(1)

The Nursing Process and Holistic Care

10

(5)

Assessment

15

(16)

Introduction

15

(1)

Purpose of Assessment

16

(1)

Database

16

(1)

Collecting Data

16

(7)

Types of Assessment

16

(1)

Comprehensive Assessment

17

(1)

Focused Assessment

17

(1)

Ongoing Assessment

17

(2)

Sources of Data

19

(1)

Types of Data

20

(3)

Validating the Data

23

(1)

Organizing the Data

23

(3)

Hierarchy of Needs

24

(1)

Body Systems Model

24

(1)

Functional Health Patterns

25

(1)

Theory of Self-Care

25

(1)

Interpreting the Data

26

(1)

Documenting the Data

26

(5)

Diagnosis

31

(10)

Introduction

31

(3)

Components of a Nursing Diagnosis

34

(1)

Two-Part Statement

34

(1)

Three-Part Statement

34

(1)

Writing the Nursing Diagnosis Statement

35

(1)

Types of Nursing Diagnoses

35

(2)

Collaborative Problems

37

(4)

Planning and Outcome Identification

41

(14)

Introduction

41

(1)

Planning

42

(1)

Prioritizing the Nursing Diagnoses

42

(1)

Identifying Outcomes

43

(2)

Goals

43

(1)

Expected Outcomes

44

(1)

Developing Specific Nursing Interventions

45

(2)

Categories of Nursing Interventions

47

(1)

Recording the Nursing Care Plan

47

(8)

Implementation

55

(8)

Introduction

55

(1)

Requirements for Effective Implementation

56

(1)

Types of Nursing Interventions

57

(1)

Documenting and Reporting Interventions

58

(5)

Evaluation

63

(8)

Introduction

63

(1)

Evaluation

63

(3)

Nursing Audit

66

(2)

Case Study

68

(3)

UNIT 2 DOCUMENTATION

71

(108)

Documentation as Communication

73

(20)

Introduction

73

(1)

Documentation Defined

73

(1)

Purposes of Health Care Documentation

74

(19)

Communication

75

(1)

Education

75

(4)

Research

79

(1)

Legal and Practice Standards

80

(1)

Informed Consent

80

(2)

Advance Directives

82

(1)

State Nursing Practice Acts

83

(1)

Joint Commission on Accreditation of Healthcare Organizations

84

(2)

Reimbursement

86

(7)

Principles of Effective Documentation

93

(16)

Introduction

93

(1)

Follow the Nursing Process

93

(2)

Elements of Effective Documentation

95

(7)

Accurate, Complete, and Objective

96

(1)

Date and Time

96

(2)

Use Appropriate Forms

98

(1)

Identify the Client

98

(1)

Write in Ink

98

(1)

Use Standard Abbreviations

99

(1)

Spell Correctly

99

(1)

Write Legibly

99

(1)

Correct Errors Properly

100

(1)

Write on Every Line

100

(1)

Chart Omissions

100

(1)

Sign Each Entry

101

(1)

Documenting a Medication Error

102

(7)

Medication Incident Report

103

(6)

Methods of Documentation

109

(20)

Introduction

109

(1)

Narrative Charting

110

(1)

Source-Oriented Charting

111

(1)

Problem-Oriented Charting

111

(1)

PIE Charting

112

(1)

Focus Charting

112

(2)

Charting by Exception

114

(1)

Computerized Charting

115

(2)

Point-of-Care Charting

117

(1)

Critical Pathway

118

(11)

Forms for Recording Data

129

(16)

Introduction

129

(1)

Kardex

129

(2)

Flow Sheets

131

(3)

Nurses' Progress Notes

134

(2)

Discharge Summary

136

(9)

Trends in Documentation

145

(10)

Introduction

145

(1)

Nursing Minimum Data Set

146

(1)

Nursing Diagnoses

146

(1)

Nursing Interventions Classification

147

(2)

Nursing Outcomes Classification

149

(6)

Reporting

155

(24)

Introduction

155

(2)

Summary Reports

157

(1)

Walking Rounds

157

(2)

Telephone Reports and Orders

159

(1)

Incident Reports

160

(7)

APPENDICES

Appendix A NANDA Nursing Diagnoses 2001-2002

167

(4)

Appendix B Abbreviations, Acronyms, and Symbols

171

(4)

Appendix C Answers to Review Questions

175

(4)

Glossary

179

(6)

Index

185

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Documentation & the Nursing Process: A Review

Summary

Table of Contents

Supplemental Materials