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

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