Anjali Jose

Department of Nursing Foundation
Sub: Nursing Foundation

Lesson plan on: Methods/ System of
Documentation
Submitted To : Mr Basavaraj
Submitted by: Anjali Jose
Lecturer
Dept of Nursing Foundation
Submitted on : 04-09-2024
Specific Objectives:
After the completion of the class , student will be able

 to define documentation
 to explain the method of documentation
 to explain the system of documentation
1
Introduction
Documentation in nursing refers to the process of recording and
maintaining accurate , concise and timely information about
patient care. It is a critical aspect of nursing practice that serves
several purposes
1. Communication : Documentation facilities communication

among the healthcare team members , ensuring that everyone is
informed about patient’s condition , treatment and progress.
2
2. Legal evidence : Accurate documentation provides legal evidence of the care
provided and can help moves and healthcare organizations in case of legal
disputes.
3. Quality improvement: Documentation helps identify areas for quality
improvement, allowing healthcare organization to develop strategies to enhance
patient care.
4. Research and education: Documentation provides valuable data for research

and education , enabling healthcare professionals to advance their knowledge and
improve practice.
3
5.Patient safety: Documentation helps ensure patient safety by enabling
healthcare professionals to track allergies, medication and other critical
information.
6. Reimbursement: Accurate documentation is essential for
reimbursement purposes, as it helps healthcare organizations receive
appropriate compensation for their services.
7. Patient engagement: Documentation can facilitate patient
engagement by providing them with access to ther health
information and encouraging them to take an active role in their care.
4
Documentation
Documentation is any written or electronically generated
informtion about a client that describes the care or service
provided to that client.
Health records may be paper documents or electronic

documents such as electronic medical records , faxes ,
emails , audio or video tapes and images.
Nurses may document information pertaining to individual

clients or groups of documentation in nursing includes:
5
1. Patient assessment and evaluation.
2. Care plans and interventions.
3. Medication adminstration.
4. Treatment and procedures.
5. Patient responses and outcomes.
6. Vital signs and laboratory results
7. Communication with other healthcare professionals
8. Patient education and discharge planning.
6
Good documentation in nursing should be:
1. Accurate
2. Clear
3. Concise
4. Timely
5. Complete
6. Legible
7. Organized
8. Confenditial
7
Methods of Documentation
Efficient documentation methods provide solution to what is
appropriate in a particular care facility or organization
Narrative : Narrative documentation is the traditional method for

nursing care provided . It is a story like format to document
information specific to client conditions and nursing care.
Data is recorded in the progress notes without an organizing
framework . It often requires the reader to sort through
information to locate the data required .
8
Problem Oriented Medical Record (POMR): This is a single
list of client problems generated by the members of the
health care team. The nursing process forms the basis for the
POMR method of documenting client problems.
SOAPIER : One of the most prominent features of this

problem- oriented method of documentation is the sructured
way in which narrative progress notes are written by all
health care team members , using the SOAP , SOAPIE or
SOAPIER format.
9
PIE (Problem Intervention Evaluation):
The PIE notes are numbered or labeled according to the
client’s problems. Resolved problems are dropped from daily
documentation .
Focus charting : This method of documentation consists of notes
that include Data , both subjective and objective; Action or nursing
interventions and response of the client . One distinction of focus
documentation is the moment away from documenting only
problems
10
Charting by exception : This system of health care recording
assessments, intervention in a manner that would reduce error in
a documentation.
11
System of Documentation
In nursing, a system of documentation is a standardized and structure
approach to recording patient information, care plans and treatment
outcomes,. It’s a crucial aspect of nursing practice, ensuring:
1. Accurate and comprehensive patient records
2. Effective communication among health care teams
3. Continuity of care
4. Legal and regulatory compliance
5. Quality improvement and research
6. Patient safety and accountability
12
Conclusion
Effective nursing documentation supports informed decision-
making, improves patient outcomes and reduces risks. It’s
essential for nurses to understand the importance of through and
accurate documentation to deliver high-quality patient care.
13
References
 Celestina Francis , Kritika Misra, Textbook of Nursing Foundation for B.Sc
Nursing students volume-Ⅰ, 2nd edittion Lotus Publishers- 2020
Page no: 98-104
 Lakwider Kaur, Maninder Kaur Text Book Of Nursing Foundation for B.sc
Nursing S. Vikas and company (Medical Publisher) INDIA. Page no:
 Slideshare.available from- https://www.slideshare.net/Slideshow/methods-of-

nursing-documentation-final/35816450
14

Anjali Jose

Uploaded by

Copyright:

Available Formats

Anjali Jose

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Anjali Jose

Uploaded by

Copyright:

Available Formats

Department of Nursing Foundation

Sub: Nursing Foundation

After the completion of the class , student will be able

1. Communication : Documentation facilities communication

4. Research and education: Documentation provides valuable data for research

Health records may be paper documents or electronic

Nurses may document information pertaining to individual

Narrative : Narrative documentation is the traditional method for

SOAPIER : One of the most prominent features of this

 Slideshare.available from- https://www.slideshare.net/Slideshow/methods-of-

You might also like