Documentation Part 2

Nursing Documentation

 provides legal evidence of care given.

• It serves as communication among members of the health team.

Accuracy, clarity, timeliness, and completeness are essential.

Medication card

 a written or printed form used to record prescribed drugs for a patient.
-  It serves as a guide for medication administration and ensures accuracy in dosage, route, and timing.

date ordered

room and bed number of patient 

Patient complete name 

name of drug + dose + form, route, frequency / time of administration 

ANST allergy noted and skin test 

front of the medication card

Date and time medication started 

patient’s birthday 

signature of nurse 

counter signature of CI or staff nurse 

Back of the card

guide for accurate administration

ensure right time and correct dosage

acts as record and reminder or Physician order

prevent medication error + promote patient sadety 

4 purpose of medication card

OD 

8am

Orange 

BID

8am 6pm 

blue

TID

8am 1pm 6pm 

white

QID

8am 12noon 4pm 8pm 

green

Round the Clock

q2 q4 q6 q8

Yellow

Stat

within 5 minutes 

Red

single dose

pink

flow sheet / monitoring sheet 

a structured chart used to record routine assessments and nursing activities for quick reference and continuity of care.

vital signs monitoring sheet

vital signs graph 

nurses monitoring sheet

medication record 

list down the common flow sheets

Vital Signs monitoring Sheet

• Records temperature, pulse, respiration, and blood pressure.

• May include pain score and oxygen saturation.
  

Vital Signs graph 

Plots vital signs on a chart for trend visualization.

Nurses monitoring sheet

• Lists activities of daily living (ADLs) such as hygiene, intake & output, elimination, diet, and ambulation.

Medication Record

Tracks medications given, including time, dosage, and initials of the administering nurse.

Focus charting 

a system of documentation that concentrates on client’s needs, problems, and strengths rather than medical diagnoses.

 It allows the nurse to organize notes using the nursing process.

Data 

• observations of client status and behavior, vital signs, and other assessment cues

• Both subjective and objective data are recorded

  • T- 39 C, skin warm to touch, flushed face noted, patient states, "I feel warm

Action

• immediate and future actions

• may include any changes to the plan of care

  • Tepid sponge bath done, instructed to increase fluid intake as tolerated, administered paracetamol 1 amp IV as per doctor's order, monitored VS every 4 hours

Response

• Describes client's response to any nursing and medical care

  • Example: Response: Temperature decreased from 39 C to 37.9 C

change in condition

significant event : treatment , procedure, observation 

client behavior requiring intervention 

health teaching or discharge instruction

progress or deterioration of status 

when to use FDAR?