{"id":5,"date":"2020-05-14T15:50:38","date_gmt":"2020-05-14T19:50:38","guid":{"rendered":"https:\/\/pressbooks.library.ryerson.ca\/documentation\/2020\/05\/14\/chapter-1\/"},"modified":"2022-03-15T15:05:42","modified_gmt":"2022-03-15T19:05:42","slug":"chapter-1","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/chapter\/chapter-1\/","title":{"raw":"Introduction to Documentation","rendered":"Introduction to Documentation"},"content":{"raw":"<p class=\"no-indent\">Documentation refers to <strong>paper<\/strong> or <strong>electronic record keeping<\/strong> about a client\u2019s state of health and their care. Paper record keeping involves using a pen to write in the client\u2019s chart, while electronic record keeping involves typing directly into a client\u2019s chart using a computerized device. A paper chart is typically in a three-ring binder or folder and is dedicated to a specific client.<\/p>\r\n<p class=\"no-indent\">These forms of record keeping are typically referred to using the interchangeable terms the \u201cclient\u2019s chart\u201d or the \u201cclient\u2019s health record.\u201d<\/p>\r\n<p class=\"no-indent\">The nurse should <strong>document all phases of the nursing process<\/strong>, including:<\/p>\r\n\r\n<ul>\r\n \t<li>\r\n<p class=\"no-indent\">Assessments, history, and observations of the client\u2019s health status including both normal and abnormal findings.<\/p>\r\n<\/li>\r\n \t<li>\r\n<p class=\"no-indent\">Diagnostics, planning, and interventions including care, treatment, services, and health teaching.<\/p>\r\n<\/li>\r\n \t<li>\r\n<p class=\"no-indent\">Evaluations of the care, treatment, and services provided, noting how the client responded, and any necessary follow-up.<\/p>\r\n<\/li>\r\n<\/ul>\r\n<p class=\"no-indent\">The components of documentation included in the client\u2019s chart will depend on the area of care and institution. For example, a nurse working on a cardiac unit will document different findings than a nurse working on a labour and delivery unit, and a client\u2019s chart will also vary by institution, such as across hospitals, out-patient clinics, primary care settings, and long-term care facilities.<\/p>\r\n&nbsp;\r\n<div class=\"textbox textbox--exercises\"><header class=\"textbox__header\">\r\n<p class=\"textbox__title no-indent\" style=\"text-align: center\"><strong>Points of Consideration<\/strong><\/p>\r\n\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n<p class=\"no-indent\"><strong>Information and Communication Technologies<\/strong><\/p>\r\n<p class=\"no-indent\">Documentation can be facilitated by using <strong>information and communication technologies<\/strong> (<strong>ICT<\/strong>); these digital technologies allow \u201cthe electronic capture, processing, storage, and exchange of information\u201d (Gagnon et al., 2012, p.241). ICT is an umbrella term used to describe the technology-based tools that nurses use in the clinical environment, including the client\u2019s electronic record. As a healthcare provider, you will be expected to use ICT to support interprofessional communication with the client and other providers, as well as to inform client care and clinical decision-making.<\/p>\r\n\r\n<\/div>\r\n<\/div>\r\n&nbsp;\r\n<p class=\"no-indent\">The next section explores the reasons for documentation.<\/p>","rendered":"<p class=\"no-indent\">Documentation refers to <strong>paper<\/strong> or <strong>electronic record keeping<\/strong> about a client\u2019s state of health and their care. Paper record keeping involves using a pen to write in the client\u2019s chart, while electronic record keeping involves typing directly into a client\u2019s chart using a computerized device. A paper chart is typically in a three-ring binder or folder and is dedicated to a specific client.<\/p>\n<p class=\"no-indent\">These forms of record keeping are typically referred to using the interchangeable terms the \u201cclient\u2019s chart\u201d or the \u201cclient\u2019s health record.\u201d<\/p>\n<p class=\"no-indent\">The nurse should <strong>document all phases of the nursing process<\/strong>, including:<\/p>\n<ul>\n<li>\n<p class=\"no-indent\">Assessments, history, and observations of the client\u2019s health status including both normal and abnormal findings.<\/p>\n<\/li>\n<li>\n<p class=\"no-indent\">Diagnostics, planning, and interventions including care, treatment, services, and health teaching.<\/p>\n<\/li>\n<li>\n<p class=\"no-indent\">Evaluations of the care, treatment, and services provided, noting how the client responded, and any necessary follow-up.<\/p>\n<\/li>\n<\/ul>\n<p class=\"no-indent\">The components of documentation included in the client\u2019s chart will depend on the area of care and institution. For example, a nurse working on a cardiac unit will document different findings than a nurse working on a labour and delivery unit, and a client\u2019s chart will also vary by institution, such as across hospitals, out-patient clinics, primary care settings, and long-term care facilities.<\/p>\n<p>&nbsp;<\/p>\n<div class=\"textbox textbox--exercises\">\n<header class=\"textbox__header\">\n<p class=\"textbox__title no-indent\" style=\"text-align: center\"><strong>Points of Consideration<\/strong><\/p>\n<\/header>\n<div class=\"textbox__content\">\n<p class=\"no-indent\"><strong>Information and Communication Technologies<\/strong><\/p>\n<p class=\"no-indent\">Documentation can be facilitated by using <strong>information and communication technologies<\/strong> (<strong>ICT<\/strong>); these digital technologies allow \u201cthe electronic capture, processing, storage, and exchange of information\u201d (Gagnon et al., 2012, p.241). ICT is an umbrella term used to describe the technology-based tools that nurses use in the clinical environment, including the client\u2019s electronic record. As a healthcare provider, you will be expected to use ICT to support interprofessional communication with the client and other providers, as well as to inform client care and clinical decision-making.<\/p>\n<\/div>\n<\/div>\n<p>&nbsp;<\/p>\n<p class=\"no-indent\">The next section explores the reasons for documentation.<\/p>\n","protected":false},"author":34,"menu_order":1,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[47],"contributor":[],"license":[],"class_list":["post-5","chapter","type-chapter","status-publish","hentry","chapter-type-standard"],"part":3,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/pressbooks\/v2\/chapters\/5","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/wp\/v2\/users\/34"}],"version-history":[{"count":19,"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/pressbooks\/v2\/chapters\/5\/revisions"}],"predecessor-version":[{"id":292,"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/pressbooks\/v2\/chapters\/5\/revisions\/292"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/pressbooks\/v2\/parts\/3"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/pressbooks\/v2\/chapters\/5\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/wp\/v2\/media?parent=5"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/pressbooks\/v2\/chapter-type?post=5"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/wp\/v2\/contributor?post=5"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/wp\/v2\/license?post=5"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}