Lecture Nursing documentation using electronic health records: Chapter 6 - Byron R. Hamilton, Mary Harper, Paul Moore

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Chapter 6
Nurse Note Documentation
Level 2

McGraw­Hill

© 2012 The McGraw­Hill Companies, Inc. All rights reserved.


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Chapter 6 Content
LO 6.1 Dx (Nursing Diagnosis)
LO 6.2 NOC (Nursing Outcomes)
LO 6.3 NIC (Nursing Interventions)
LO 6.4 MAR (Medication Administration
Record)
LO 6.5 I&O (Intake and Output)


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LO 6.1 DX (NURSING
DIAGNOSIS)


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LO 6.1 Dx (Nursing Diagnosis)

• Standardized language
– Mechanism for communication
– Reflects nursing practice
– Facilitates use of technology
– Allows comparison of nursing activities
– Used in research
– Promotes quality patient care
– 12 systems recognized by ANA


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LO 6.1 Dx (Nursing Diagnosis)
• NANDA-I nursing dx, NOC, NIC
– Widely recognized
– Research based
– Comprehensive


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LO 6.1 Dx (Nursing Diagnosis)
• Nursing process
– Assessment/diagnosis
– Planning
– Intervention
– Evaluation


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LO 6.1 Dx (Nursing Diagnosis)
• Assessment
– First step in nursing process
– Subjective data
• Report of patient and/or family

– Objective data
• Observations of nurse
–
–
–
–

Observation
Auscultation
Palpation
Smell


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LO 6.1 Dx (Nursing Diagnosis)
• Assessment data used to formulate
nursing dx
• Nursing diagnosis
– “Clinical judgment about individual, family, or
community experiences and responses to
actual or potential health problems and life
processes” (NANDA-I)

– Key = patient response to illness

• Medical diagnosis
– Disease process


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LO 6.1 Dx (Nursing Diagnosis)
• Nursing diagnosis
– Prioritized
• High priority = Airway, Breathing, Circulation
(ABCs)
• Mid priority = threat to health or ability to cope
• Low priority = delayed intervention will not cause
harm


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LO 6.1 Dx (Nursing Diagnosis)
• To assign nursing dx
– Collect subjective and objective data
– Analyze data to identify actual and potential
problems
– Assign nursing dx
– Individualize nursing dx
• Etiology (related to)
• Signs & symptoms (as evidenced by)

– Place in order of priority


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LO 6.1 Dx (Nursing Diagnosis)
• Research evidence
– Use of nursing diagnoses improves
documentation of assessments
– Inclusion of etiology in nursing dx improves
both interventions and outcomes
– Muller-Staub, M. (2009) “Evaluation of the
implementation of nursing diagnoses, outcomes and
interventions.” International Journal of Nursing
Terminologies and Classifications, 20(1), 9–15.


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LO 6.2 NOC (NURSING
OUTCOMES)


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LO 6.2 NOC (Nursing
Outcomes)
• Planning phase of nursing process
– Determine desired patient outcomes
• Short term goals

• Long term goals

– Individualize for the patient


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LO 6.3 NIC (NURSING
INTERVENTIONS)


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LO 6.3 NIC (Nursing
Interventions)
• Nursing interventions
– Nursing actions to help patient achieve goals
• Facilitate wellness
• Facilitate movement toward wellness

– Individualized for patient


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LO 6.4 MAR
(MEDICATION ADMINISTRATION
RECORD)

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LO 6.4 MAR
(Medication Administration Record)
• The Nursing Documentation area in
Spring-Charts allows nurse to use
additional documents and/or spreadsheets
to document items such as medication
administration, intake and output (I&O),
sedation scale, and falls risk assessment.
– INSERT WHERE STUDENTS FIND FILES


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LO 6.4 MAR
(Medication Administration Record)
• Legal consideration:
– Nurses responsible for their own actions
– Medication orders that are not consistent with
prescribing guidelines should be clarified
before administration
– Nurses have the right to refuse to administer a
medication if the orders are not clear or
consistent with prescribing guidelines


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LO 6.4 MAR

(Medication Administration Record)
• Elements included in MAR
– Drug name
– Drug dosage
– Drug route
– Frequency of administration
– Administration times


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LO 6.4 MAR
(Medication Administration Record)
• Holding medications
– Document reason medication not given per
facility policy
– Notify licensed practitioner who ordered the
medication


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LO 6.5 I&O (INTAKE AND
OUTPUT)


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6.5 I&O (Intake and Output)
• Intake

– All fluids
• Oral
• Parenteral, including blood products and meds

• Output
– All fluids
• Urine
• Emesis
• Drainage tubes