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

Chapter 4 - Nurse note documentation, level 2. After completing Chapter 6, the students will be able to: Use NANDA-International (NANDA-I) approved nursing diagnoses to reflect patient needs, identify patient specific goals using Nursing Outcomes Classification (NOC), identify and document nursing interventions using Nursing Intervention Classification (NIC), carry out documentation of medication administration, carry out documentation of intake and output (I&O).

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)

LO 6.1 DX (NURSING

DIAGNOSIS)

– 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

– Widely recognized

– Research based

– Comprehensive

– Assessment/diagnosis

– Planning

– Intervention

– Evaluation

– First step in nursing process

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

– Prioritized

• High priority = Airway, Breathing, Circulation (ABCs)

• Mid priority = threat to health or ability to cope

• Low priority = delayed intervention will not cause harm

– 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

– 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.

LO 6.2 NOC (NURSING

OUTCOMES)

– Determine desired patient outcomes

• Short term goals

• Long term goals– Individualize for the patient

LO 6.3 NIC (NURSING

INTERVENTIONS)

– Nursing actions to help patient achieve goals

• Facilitate wellness

• Facilitate movement toward wellness– Individualized for patient

LO 6.4 MAR (MEDICATION ADMINISTRATION

RECORD)

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

– Nurses responsible for their own actions

– Medication orders that are not consistent with

prescribing guidelines should be clarified

– Document reason medication not given per

facility policy

– Notify licensed practitioner who ordered the

medication

LO 6.5 I&O (INTAKE AND

OUTPUT)