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

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