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
- Problem-oriented recording
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
