IRJMST Vol 8 Issue 7 [Year 2017] ISSN 2250 – 1959 (0nline) 2348 – 9367 (Print)
PAEDIATRICS NURSING - Nursing documentation
SONIYA LINET FERNANDES
M.Sc Nursing
Asso. Professor
Rajeev Gandhi University of Health Sciences, Bangalore
Introduction
Nursing documentation is essential for good clinical communication. Appropriate legible
documentation provides an accurate reflection of nursing assessments, changes in conditions, care
provided and pertinent patient information to support the multidisciplinary team to deliver great care.
Documentation provides evidence of care and is an important professional and medico legal
requirement of nursing practice.
Aim
To provide a structured and standardised approach to nursing documentation for inpatients. This will
ensure consistency across the RCH and improve clinical communication.
Definition of Terms
Documentation: encompasses all written and/or electronic entries reflecting all aspects of patient care
communicated, planned recommended or given to that patient.
‗End of shift‘ progress notes: nursing documentation written as a summary at the end or towards the
end of shift.
‗Real time‘ progress notes: nursing documentation written in a timely manner during the shift.
ISBAR: (Identify, Situation, Background, Assessment, Recommendation) framework for clinical
communication
Admission assessment: Comprehensive nursing assessment including patient history, general
appearance, physical examination and vital signs completed at the time of admission.
Shift assessment: Concise nursing assessment completed at the commencement of each shift or if
patient condition changes at any other time during your shift.
Process
Nursing documentation will support the process;
Patient assessment,
Plan of care
Real time progress notes
Patient assessment
International Research Journal of Management Science & Technology
http://www.irjmst.com Page 182
, IRJMST Vol 8 Issue 7 [Year 2017] ISSN 2250 – 1959 (0nline) 2348 – 9367 (Print)
An admission assessment is completed and documented on the Nursing Admission (MR850/A) as
per Nursing assessment guideline.
Exceptions: See Special Considerations
At the commencement of each shift, following handover, patient introductions and safety checks, a
‗commencement of shift assessment‘ is completed as outlined in the Nursing assessment guideline.
These assessments are documented on the Patient Care Plan (MR 856/A). If there is more
information gained from this assessment than space allowed, additional information is documented
in the progress notes. In Neonates (Butterfly) and PICU (Rosella), commencement of shift
assessments are completed in progress notes.
Plan of Care
Taking into consideration the patient assessment, clinical handover, previous patient documentation
and verbal communication with the patient and family the plan of care for the shift is made and
documented on the Patient Care Plan (MR 856/A). The plan should be negotiated with patients‘ and
their carers to ensure clear expectations of care, procedures, investigations and discharge, are set
early in the shift. The plan of care should align with information on the patient journey board.
Real time Progress Notes
Documentation is captured in the patient‘s progress notes in ‗real time‘ throughout the shift instead
of a single entry at the end of shift.
Any relevant clinical information is entered in a timely manner such as;
Abnormal assessment, eg. Uncontrolled pain, tachycardic, increased WOB, poor perfusion,
hypotensive, febrile etc.
Change in condition, eg. Patient deterioration, improvements, neurological status,desaturation, etc.
Adverse findings or events, eg. IV painful, inflamed or leaking requiring removal, vomiting, rash,
incontinence, fall, pressure injury; wound infection, drain losses, electrolyte imbalance, +/-fluid
balance etc.
Change in plan (Any alterations or omissions from plan of care on patient care plan) eg. Rest in bed,
increase fluids, fasting, any clinical investigations (bloods, xray), mobilisation status, medication
changes, infusions etc.
Patient outcomes after interventions eg. Dressing changes, pain management, mobilisation, hygiene,
overall improvements, responses to care etc.
Family centred care eg. Parent level of understanding, education outcomes, participation in care,
child-family interactions, welfare issues, visiting
arrangements etc.
Social issues eg. Accommodation, travel, financial, legal etc.
International Research Journal of Management Science & Technology
http://www.irjmst.com Page 183
PAEDIATRICS NURSING - Nursing documentation
SONIYA LINET FERNANDES
M.Sc Nursing
Asso. Professor
Rajeev Gandhi University of Health Sciences, Bangalore
Introduction
Nursing documentation is essential for good clinical communication. Appropriate legible
documentation provides an accurate reflection of nursing assessments, changes in conditions, care
provided and pertinent patient information to support the multidisciplinary team to deliver great care.
Documentation provides evidence of care and is an important professional and medico legal
requirement of nursing practice.
Aim
To provide a structured and standardised approach to nursing documentation for inpatients. This will
ensure consistency across the RCH and improve clinical communication.
Definition of Terms
Documentation: encompasses all written and/or electronic entries reflecting all aspects of patient care
communicated, planned recommended or given to that patient.
‗End of shift‘ progress notes: nursing documentation written as a summary at the end or towards the
end of shift.
‗Real time‘ progress notes: nursing documentation written in a timely manner during the shift.
ISBAR: (Identify, Situation, Background, Assessment, Recommendation) framework for clinical
communication
Admission assessment: Comprehensive nursing assessment including patient history, general
appearance, physical examination and vital signs completed at the time of admission.
Shift assessment: Concise nursing assessment completed at the commencement of each shift or if
patient condition changes at any other time during your shift.
Process
Nursing documentation will support the process;
Patient assessment,
Plan of care
Real time progress notes
Patient assessment
International Research Journal of Management Science & Technology
http://www.irjmst.com Page 182
, IRJMST Vol 8 Issue 7 [Year 2017] ISSN 2250 – 1959 (0nline) 2348 – 9367 (Print)
An admission assessment is completed and documented on the Nursing Admission (MR850/A) as
per Nursing assessment guideline.
Exceptions: See Special Considerations
At the commencement of each shift, following handover, patient introductions and safety checks, a
‗commencement of shift assessment‘ is completed as outlined in the Nursing assessment guideline.
These assessments are documented on the Patient Care Plan (MR 856/A). If there is more
information gained from this assessment than space allowed, additional information is documented
in the progress notes. In Neonates (Butterfly) and PICU (Rosella), commencement of shift
assessments are completed in progress notes.
Plan of Care
Taking into consideration the patient assessment, clinical handover, previous patient documentation
and verbal communication with the patient and family the plan of care for the shift is made and
documented on the Patient Care Plan (MR 856/A). The plan should be negotiated with patients‘ and
their carers to ensure clear expectations of care, procedures, investigations and discharge, are set
early in the shift. The plan of care should align with information on the patient journey board.
Real time Progress Notes
Documentation is captured in the patient‘s progress notes in ‗real time‘ throughout the shift instead
of a single entry at the end of shift.
Any relevant clinical information is entered in a timely manner such as;
Abnormal assessment, eg. Uncontrolled pain, tachycardic, increased WOB, poor perfusion,
hypotensive, febrile etc.
Change in condition, eg. Patient deterioration, improvements, neurological status,desaturation, etc.
Adverse findings or events, eg. IV painful, inflamed or leaking requiring removal, vomiting, rash,
incontinence, fall, pressure injury; wound infection, drain losses, electrolyte imbalance, +/-fluid
balance etc.
Change in plan (Any alterations or omissions from plan of care on patient care plan) eg. Rest in bed,
increase fluids, fasting, any clinical investigations (bloods, xray), mobilisation status, medication
changes, infusions etc.
Patient outcomes after interventions eg. Dressing changes, pain management, mobilisation, hygiene,
overall improvements, responses to care etc.
Family centred care eg. Parent level of understanding, education outcomes, participation in care,
child-family interactions, welfare issues, visiting
arrangements etc.
Social issues eg. Accommodation, travel, financial, legal etc.
International Research Journal of Management Science & Technology
http://www.irjmst.com Page 183
