Documentation.."10 key components"?

  1. I was wondering if anyone might be able to answer something for me. We did case studies in my Nursing Fundementals class last week working with partners. One of the questions we answered has me a little confused (thank goodness I had a partner!)It was in regards to wound care. We were given a scenario, with an MAR (orders from doc) and at 1000 we were supposed to perform the dressing change of his surgical wound. Our directions were to write a nursing note of your assessment incorporating ten key components....I am wondering if she just meant "include ten important things to document" or if there is a RULE for this (such as the 5 Rights...) for documentation?? We recorded it as:

    1000 Right hip dehiscence of surgical incision 15 cm X 8 cm X 3 cm. Full thickness skin loss with no bone or muscle involvement. Wound bed has slight exudate with granulation tissue present in 50% of wound. Exudate = minimal serous < 10 mL per bandage change. Would edges proliferative and dry. Surrounding skin dry, pink and warm to touch around wound. Pain of 8 to 10 per patient. Applied wet to moist dressing per Dr. order and would flushed with 0.9% saline per Dr. order. (signature)

    We got all points on it....but I am just wondering if there are "10 key components" that I am not aware of...I would email and ask my instructor but the final for this class is in the morning, and I am certain she won't reply to my email by then...

    And just to reclarify...I don't need help with the documentation part...ONLY ON what the "10 key components" in documentation means. Thanks to anyone who can help!

    ~J
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  2. 2 Comments

  3. by   VickyRN
    Just throwing out a few ideas/ thoughts:
    You want to make sure that the right information is documentated and that the documentation is done correctly.

    Documentation should be:
    • Legible
    • Accurate
    • Clear
    • Concise
    • Complete (include pertinent health or drug information)
    • Objective (no judgment statements, interpretations, or medical diagnoses)
    • Timely (chart as you go)
    • Use ONLY approved abbreviations
    • Medications that have been given (dose, route, time, pt response, adverse reactions, follow through if discontinued)
    • Sign your full name and title somewhere on every page where you've charted.
    • Don't leave blank spaces, lines, or boxes on charts.


    Remember the nursing process while charting: Assess, Plan, Nursing Diagnosis, Interventions, and Evaluation.
    WHEN you chart a problem, you must ALWAYS chart your intervention (nursing actions).
    When you chart your intervention, you must ALWAYS follow up with an evaluation.

    http://www.malenursemagazine.com/charting.html
    http://medi-smart.com/law-forensic.htm
    http://www.nso.com/newsletters/features/common.php
    http://medi-smart.com/documentation-article.htm
  4. by   RNin2007
    Thank you once again Vicki! This makes a lot of sense. You are my personal hero this weekend =).

    ~J

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