Documentation Components – Documentation in Nursing: 1st Canadian edition

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Top Highlights

• allergies

• information about the client including their name, age and date of birth, gender, contact information/address, admission date, reason for admission, and next of kin and/or emergency contacts

• allows for open-ended documentation

• client’s health status and/or responses to interventions

• expertise about a client’s healthcare status/condition

• advice related to the plan of care

• orders related to diagnostic tests (e.g., ultrasound, X-ray orders), laboratory orders (e.g., blood, urine tests), or therapeutic orders (e.g., medications, diet, mobility orders)

• list of all medications that are ordered for the client: medication name, dose, route, frequency, date the medication was ordered, and the date it will expire

• As the nurse, you must document the date and time, and sign and initial the MAR, when you prepare and provide any medication

• physiological data like vital signs, pain, and weight

• hygiene, mobility, nutrition, and the use of restraints

• commonly completed by nurses

• daily care

• information

• specific details of a procedure and any complications

• they should be written in clear and non-medicalized language that the client can understand

• include

• any unintended event that occurs when a patient receives treatment in a hospital, (a) that results in death, or serious disability, injury or harm to the patient, and (b) does not result primarily from the patient’s underlying medical condition or from a known risk inherent in providing treatment.

• monitor client care needs (e.g., number of care hours required)

• you will usually complete these at the end of each shift; they may involve electronic tracking of the amount time spent with each client