Nurse's Pocket Guide

documentation of the planning process and serves as a framework/outline
for charting of administered care. The primary
nurse needs to periodically review the client’s progress and the
effectiveness of the treatment plan. Other care providers then
are able to read the notes and have a clear picture of what
occurred with the client and make appropriate judgments
regarding client management. The best way to ensure the clarity
of progress notes is through the use of descriptive (or observational)
statements. Observations of client behavior and
response to therapy provide invaluable information. Through
this communication it can be determined if the client’s current
desired outcomes or interventions can be eliminated or need to
be altered and if the development of new outcomes or interventions
is warranted. Progress notes are an integral component of
the overall medical record and should include all significant
events that occur in the daily life of the client. They reflect
implementation of the treatment plan and document that
appropriate actions have been carried out, precautions taken,
and so forth. It is important that both the implementation of
interventions and progress toward the desired outcomes be documented.
The notes need to be written in a clear and objective
fashion, specific as to date and time, and signed by the person
making the entry.
Use of clear documentation helps the nurse to individualize
client care. Providing a picture of what has happened and is
happening promotes continuity of care and facilitates evaluation.
This reinforces each person’s accountability and responsibility
for using the nursing process to provide individually
appropriate and cost-effective client care.
PUTTING THEORY INTO PRACTICE 19