Documentation of the steps of the nursing process

Documentation

• Documentation of the steps of the nursing process is often considered as evidence in determining certain cases of negligence by nurses.
• It is also required by some agencies that accredit healthcare organizations.
• Examples of documentation that reflect use of the nursing process
  • Problem-oriented recording   
    • Has a list of problems as its basis
    • Uses subjective, objective, assessment, plan, intervention, and evaluation format
  • Focus charting
    • Main perspective is to choose a “focus” for documentation.
    • The focus cannot be a medical diagnosis.
    • Focus charting uses a data, action, and response format.
  • A P I E method
    • A problem-oriented system
    • Uses flow sheets as accompanying documentation
    • Uses assessment, problem, intervention, and evaluation (A P I E) format

Electronic Documentation

• Most healthcare facilities have implemented, or are in the process of implementing, some type of electronic health records (E H R’s) or electronic documentation system.
• E H R’s have been shown to improve both the quality of client care and the efficiency of the healthcare system.

Eight core functions of E H R’s

• Health information and data
• Results management
• Order entry/order management
• Decision support
• Electronic communication and connectivity
• Patient support
• Administrative processes
• Reporting and population health management