Some items that nursing documentation charts typically include are the results of a head-to-toe physical assessment, plan of care and progress notes, according to The Royal Children's Hospital Melbourne. The purpose of nursing charts and documentation is to facilitate communication of their patients' health status between providers and create an accurate record of all encounters and interventions that were completed with the patient, explains GroupHealth.
For their nursing assessments, nurses must document their patients' overall appearance, vital signs, physical assessment data and well being, reports The Royal Children's Hospital Melbourne. Physical assessment is objective information about the patients' respiratory status, circulation and skin condition and a focused assessment on systems related to patient diagnoses. Nurses also chart their patients' intake of food, nutritional status, intake of fluids and urine output.
Progress notes are a way for nurses to document their patients' clinical status and the results of reassessment after interventions are performed, explains The Royal Children's Hospital Melbourne. Nurses use progress notes when there are abnormal lab or assessment results, changes in condition and changes in the plan of care and to document how patients responded to various interventions. Nurses should complete progress notes in real-time and not wait till the end of a shift. Nurses often use ISBAR for documenting progress notes, which stands for identification, situation, assessment, action, response and recommendation.