The purpose of documentation is to clearly communicate the condition of the patient as well as the assessment, planning, implementation, and evaluation work of nursing.

It is a continual and ongoing process that reflects the changing needs and conditions of the patient.

Documentation is the critical and sometimes only form of communication among all health care providers about the current condition of a patient.


Currently patient care documentation is found in a variety of forms and formats, handwritten and computerized.

Written documentation systems have been developed to assist clinicians to produce accurate and comprehensive documentation. Examples include the following: (a) problem-intervention-evaluation charting (PIE); (b) subjective-objective-assessment-plan charting (SOAP); (c) problem-oriented medical record charting (POMR); and (d) charting by exception formats, outcome-based charting; and critical pathways ( ).

Checklists for exception charting to address the time restraints have been implemented as documentation requirements for regulatory compliance increase.

At times, nurses shortcut documentation because of time constraints or limitations of these forms at the expense of complete charting.


As patient care becomes increasingly complex, the importance of timely and accurate documentation becomes increasingly important.

Delays, omissions, and errors in documentation may result in delays or errors in assessments, interventions, treatments, procedures, and medication administration.

These errors often create a cascade of events that may negatively impact patient care or patient outcome.

Computerized documentation systems

Computerized documentation systems are more than automation of existing paper forms.

State-of-the-art documentation systems are designed to more closely reflect the flow of patient care processes in an orderly way and to increase patient safety within the available features and design.

Computerized clinical documentation systems that support functional requirements contribute significantly to patient safety and caregiver effectiveness.

Computerized documentation systems

Safe nursing practice is supported in the following ways with an electronic record that includes:

Design of documentation systems that more closely reflect actual work processes and patient throughput, supporting clinician assessments and work organization

Integration of physician order entry, medication administration, and clinician documentation systems

Inclusion of a framework that encompasses nursing knowledge functions as a cognitive map for clinicians (nurses handle large amounts of data and often experience overload and stress; also provides professional support in making complex clinical decisions) and increases efficiency ( )

Computerized documentation systems

Integration of standards-based organizing frameworks such as Nursing Interventions (NIC), Nursing Outcomes (NOC), and North American Nursing Diagnosis Association (NANDA)

Use of a complex and comprehensive database for patient and nursing research

Inclusion of alerts, popups, and protocols to guide caregivers in both care processes and documentation

Computerized documentation systems

Specific outcomes from computerized documentation that have an impact on patient safety and decrease the potential for practice breakdown include:

Elimination of illegibility

Minimized duplication

Improved response time to patient requests

Computerized documentation systems

Specific outcomes from computerized documentation that have an impact on patient safety and decrease the potential for practice breakdown include:

Improved documentation completeness

Increased compliance with regulatory requirements (e.g., assessments for pain level, skin integrity, and fall risk)

Simultaneous, real-time access to up-to-date patient data for multiple clinicians

Computerized documentation systems

Issues with computerized documentation:

If there are rigid rules for documenting the administration of medications within one-half hour of administration, and the patient-to-nurse ratio is too high, the nurse may be tempted to document before actually administering the medication.

This sets the patient up for undetected “missed doses” of medication.

If the workflow and patient care record are poorly designed, requiring excessive amounts of time for access, then nurses may not have a chance to document their assessments and treatments in a timely manner.

Nondocumented therapies place patients at great risk for second doses of narcotics, sedatives, or other medications.

Computerized documentation systems

Issues with computerized documentation:

The down side of the extensive requirements for documentation in today's complex hospitals is that the nurse can spend from 13% to 28% of his or her time in patient care documentation, and this reduction in the nurses' availability to provide direct patient care has been shown to diminish patient safety ( ;  ;  ).


Discuss the HISTORICAL CASE STUDY described on Ebook: (Page 50)



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