After an admission assessment, nursing diagnoses and treatment plans are documented in the client’s record. Documentation is critically important for legal purposes, continuity of care, costing-out nursing services, reimbursement, and planning staffing of units. Currently, there is a transition from paper charts and a Kardex to computerized documentation in an electronic information system.

A commonly used documentation method, the problem-oriented record, is useful for both students and expert clinicians. This paper or electronic format for documentation provides (1) an indexing system for easy retrieval of information, (2) checkpoints for self-evaluation of diagnostic and therapeutic judgments, and (3) a master problem list (client problems listed by number) to increase coordination of treatment plans among care providers. As the example on pp. 51-54 illustrates, it includes the problem, supporting data, and the plan of care. Each diagnosis is given a number and entered on the master problem list. Following the documentation of the admission nursing history and examination, the problem number, nursing diagnosis, clinical data, and plan are recorded. Guidelines for recording are on pp. 45-47. The same problem number is used for all subsequent charting on a specific nursing diagnosis. An example of recording a nursing history and examination, diagnoses, and treatment plans using a paper-based method is on pp. 47-54.

Subjective or objective data related to a disease or its treatment are documented in the client’s record by number (e.g., #2 Diabetes mellitus). Relabeling of the medical problem to document the related nursing care is not necessary (e.g., alteration in glucose metabolism or alteration in cardiac output). In fact, relabeling in an indexing system leads to communication errors.

In some clinical settings without computerized records, a Kardex is used; nursing diagnoses (problem/etiology), treatments, and outcomes are listed on the Kardex. Medical diagnoses, doctor’s orders, and any related nursing orders with regard
to observation or monitoring, drugs, treatments, and standard diagnostic and treatment protocols are also placed on the Kardex. Additional nursing orders, such as those related to observation of disease or individualization of disease treatments, are also listed on the Kardex. These nursing orders are within the collaborative domain of nursing practice and do not alter the medical treatment of disease.

With these methods of documentation, the client’s record will reflect nursing judgments, actions, and evaluations relative to nursing and medical diagnoses. The Kardex will serve as a quick reference to all client problems that require nursing attention.