Nursing Documentation Examples This section includes a nursing documentation sample. 29 February 2020 1145 - Pt arrives with fever, labored breathing and disorientation. Reports chills, proximal pain in both upper and lower limbs, radiating to mid-leg and arm, 6/10. VS: BP-115/75 HR-105 RR-9 Temp 104 Pulse Ox 93% on RA. Nursing documentation is an integral part of clinical documentation and is a fundamental nursing responsibility. Good documentation ensures continuity of care, furnishes legal evidence of the process of care and supports evaluation of patient care. Nurses must balance clinical documentation with respect to legal imperatives. A number of frameworks are currently available to assist with nursing documentation including narrative charting, problem orientated approaches, clinical pathways, and focus notes. However many nurses still experience barriers to maintaining accurate and legally prudent documentation. A review of nursing documentation of patient care and General guidelines for daily nursing documentation (Campos, 2009; Scruth, 2014; Springer, 2007): Documentation should be: Accurate, relevant, and consistent. Clear, concise, and complete. Legible/readable (written and/or as displayed on electronic health record system screens) Logical, timely and sequential. Utilize a patient-centered approach. 25 Legal Dos and Don'ts of Nursing Documentation Transcript 3. Don't jump to conclusions. It is your job to observe carefully. It is your job to chart data, not conclusions. For example, a patient is found on the floor. Did the patient fall out of bed? Did the patient fall trying to ambulate on his or her own when they knew they should not have? Updated on July 8, 2013. By Matt Vera, BSN, R.N. ADVERTISEMENTS. Documentation is anything written or printed that is relied on as a record of proof for authorized persons. Documentation and reporting in nursing are needed for continuity of care it is also a legal requirement showing the nursing care performed or not performed by a nurse. It is well-known that documenting is one of the most tedious aspects of bedside nursing. It takes time away from patient care and may be used for (or against) you in court. In this CE module we will learn how to document properly. Proper documentation is an essential for defense against claims and continuity/quality of care in nursing. 1. Documentation of nursing care is recorded in the medical record and is reflective of the care provided by nursing staff. 2. Nursing care documented in the medical record will be accurate, complete, and legible. 3. Nursing care will be documented in real time, as close to the time that care was provided and information obtained as possible. GUIDELINES FOR DOCUMENTATION AND RECORD KEEPING The basic guidelines for good practice in documentation and record keeping apply equally to written records and to computer- held records. The Nursing and Midwifery Council (NMC 2002) has said that patient and client records should: - Be based on fact, correct and consistent. The documentation needs to be concise, legible, and clear. There must be accurate information about the actions taken, assessments, treatment outcomes, complications, risks, reassessment processes in treatments, and changes in the treatment. Always meet the medical and legal requirements while writing the documentation. Careful nursing assessment makes spotting changes in the pati