Association of Nursing Services

Administrators of the Philippines, Inc.

IV THERAPY
DOCUMENTATION
 History of
IV Therapy in the Philippines

1991 – RA 7164 (The

Philippine Act of 1991)
Sec. 27 (a) Art. V states
that IV injection is within
the scope of nursing
practice.
 History of
IV Therapy in the Philippines

1993 – Nursing Standards

on Intravenous
Practice was
established.
 History of
IV Therapy in the Philippines

October 1993 – Training for

Trainers for ANSAP Board
Members and Advisers at the
Philippine Heart
Center.
 History of
IV Therapy in the Philippines

February 4, 1994 – PRC-BON

Resolution No. 08 states that
a RN is prohibited from
administering intravenous
injections unless he has
undergone a special training.
 History of
IV Therapy in the Philippines
1994 - PRC-BON Resolution
No. 08 also states that any
RN without such training who
administered injections to
patient shall be held liable
either criminally,
administratively, or both.
 History of
IV Therapy in the Philippines
June 9-11, 1994 – Training for
Trainers at Cagayan de Oro
City.
May 17, 1995 – Protocol
Governing Special Training
on the Administration of IV
Injections for RNs adopted
ANSAP's IV Nursing
 History of
IV Therapy in the Philippines
June 13, 1995 – Department
Circular No. 100.S.1995 was
disseminated by DOH.
2002 – Special Committee
by ANSAP in collaboration
with PRC-BON was
founded.
 History of
IV Therapy in the Philippines

2002 – RA 9173 (Philippine

Nursing Law of 2002) again
states that the administration
of parenteral injection is
within the scope of nursing
practice.
 History of
IV Therapy in the Philippines

August 25, 2006 – Nursing

Standards on Intravenous
Practice 7th ed was released
by Association of Nursing
Service Administrators of the
Philippines (ANSAP).
 OUR VISION

ANSAP is the premier

organization in Nursing
Practice and Development
recognized worldwide.
CORE PURPOSE

LEAD in the perpetual quest

of excellent nursing practice.
 OUR MISSION
Valuing human life and
recognizing its diversity,
ANSAP is responsible to the
nursing profession, its
patients, families,
communities, and partners
in healthcare.
 OUR MISSION
We are preferred around
the world for our competence
in primary healthcare and
service management
differentiated by our integrity
and our own traditional
Filipino value of compassion.
 OUR MISSION
We collaborate with our
partners in the promotion of
safe and comprehensive
healthcare.
 OUR MISSION
We spearhead the intelligent
application of advance technologies
in health maintenance, illness
prevention and containment for the
benefit of the greater populace. In
pursuit of innovation in our field, we
will champion evidence-based
nursing practice and research.
 OUR MISSION
We are a financially sustainable
organization. Our growth is
fueled by the expansion of our
membership and our network of
partners. We exercise utmost
prudence in the utilization of our
resources.
 OUR MISSION
We are recognized by out
communities for our self-less
service.

We promote a healthy work-life

balance, espousing security of
tenure and career development
among our employees.
 CORE
VALUES
 CORE
VALUES

GOD-CENTERED
INTEGRITY

COMMITMENT
TO SERVICE

COMPASSION

COMPETENCE
STATUS OF IV THERAPY IN THE
PHILIPPINES
SCOPE OF PRACTICE

ROLE DEFINITION
The IV nurses are registered
nurses committed to ensure the
safety of all patients receiving
IV Therapy.
STATUS OF IV THERAPY IN THE
PHILIPPINES
Definition of Practice

ETHICO-LEGAL IMPLICATIONS:

ANSAP, Inc. upholds quality

nursing practice and is going to
continue with the IV Therapy
Training for the following reasons:
STATUS OF IV THERAPY IN THE
PHILIPPINES
A. Nursing curriculum does not
provide in-depth training in
parenteral IV drug
administration.
a.1. An in-depth IV Training
maybe included in the BSN
curriculum but without actual
IV insertion to patients.
STATUS OF IV THERAPY IN THE
PHILIPPINES
a.2. ANSAP believes that
parenteral IV drug
administration is an invasive
procedure.
b. The Nurse Administrator has the
command responsibility for the
whole nursing practice in the
Health Care Facility.
STATUS OF IV THERAPY IN THE
PHILIPPINES
c. Globally, the IV Therapy
certification is a mandatory
requirement for the nurse
practitioner
STATUS OF IV THERAPY IN THE
PHILIPPINES
d. IV Therapy Training is voluntary;
only those nurses who are
adequately trained and have
completed the training
requirements in the IV Therapy
Program for Nurses as prescribed
by ANSAP will be issued an IV
Certificate of Training and the IV
Therapy card of ANSAP
Trends in IV Therapy

81% - 85% patients in the hospital

receive some form of IV therapy
More nursing time is spent to IV
therapy Multi-disciplinary health
care setting
Why do we need to be updated
regarding IV therapy?

More medications are being

administered intravenously now
than before.
Nurses are assuming greater
responsibilities related to IV
medication administration.
Why do we need to be updated
regarding IV therapy?

In the world of nursing and

malpractice, the best way to avoid
having defend yourself is to chart
factually and defensively.

The best offense is the good

defense.
Why do we need to be updated
regarding IV therapy?
This involves knowing:
HOW to chart
WHAT to chart

WHEN to chart
WHO to chart
THE PATIENT’S
CHART IS
MORE
THAN A LEGAL
RECORD
Use Language that is
OBJECTIVE and that
paints a PICTURE OF
THE PATIENT
PRIMARY PURPOSE OF
CHARTING
1. Charting provides a way for
health team professionals to
communicate with each other.
2. Charting provides a legal
record that can be used to
protect the patient, the health
professional and health facility
who provide care
PRIMARY PURPOSE OF
CHARTING
3. Charting provides the data
needed for effective
interdisciplinary care and to
ensure continuity of care
4. Charting furnishes a written
record of the quality of care
PRIMARY PURPOSE OF
CHARTING
5. Charting provides information
for the care team to learn
6. Charting provides a record
of service rendered and
equipment used for cost
accounting and reimbursement.
PRIMARY PURPOSE OF
CHARTING

7. Charting is mandated by
DOH.
LEGAL ISSUES OF
DOCUMENTATION
1. Chart accurately and
concisely. TELL THE TRUTH
2. Follow the documentation
policy of the institution
3. Keep charting free of
criticisms or complaints
GENERAL PRINCIPLES OF
DOCUMENTATION
1. ACCURACY
Documented observations
should give an appropriate
picture of the client’s
situation
Don’t : Vital signs normal.
Do:BP:120/80 HR:89 RR:18 T:36.8
GENERAL PRINCIPLES OF
DOCUMENTATION
2. Complete

a.Document ALL pertinent data without

omissions of information on client’s
condition.
b.Document assessment, problems
identified, interventions and evaluation of
the care rendered.
GENERAL PRINCIPLES OF
DOCUMENTATION
3. Factual

– Must be based on facts of what actually

observed, done and evaluated.

4. Clear
- Words used in documentations should
be understandable and comprehensible.
GENERAL PRINCIPLES OF
DOCUMENTATION
5. Appropriate
- Information should be proper and
suitable to what actually observed,
diagnosed, done and evaluated.

6. Concise
a. Brief and direct to the point.
b. Record only what is important
c. Avoid using a long word when a
short word can do
GENERAL PRINCIPLES OF
DOCUMENTATION
7. Current
- Document the recent and existing
condition of the patient.

-Pace yourself to document on a

timely format.
Do’s in Documentations

 Review notations before signing them.

This helps minimize the need for
subsequent corrections or addenda.
 Make all entries at the time of
treatment, examination or
procedure or as soon after as
possible.
 Draw a line through any empty
space at the end of an entry or at
the bottom of the page.
Do’s in Documentations
 Complete all boxes or blanks if
forms are used. If no information is
available or an item on the form is
not applicable, indicate this in the
box or blank so that it is clear that
you didn’t disregard the item.
 Make sure the record
acknowledges patients complaints
and concerns and indicates that
they are taken seriously.
Do’s in Documentations

 Use only hospital-approved

abbreviations and symbols.

 Include clinically relevant

information about a complication,
error, misadventure, etc. How the
situation was handled
administratively does not belong in
the medical record.
Do’s in Documentations

 Stick to the facts and choose your

words carefully if a mishap occurs. Do
not argue your case in the medical
record. Defensive entries can damage
the credibility of the entire record.
OBSOLETE REASON SUGGESTED
TERM PHRASE

Conscious & only for patient's patient oriented to

Coherent whose neuro-logical date, time and place
status is affected
and disoriented
 OBSOLETE REASON SUGGESTED
TERM PHRASE

Vital signs taken vital signs are document if you

already written on were not able to
the monitoring take VS and why
sheet
 OBSOLETE REASON SUGGESTED
TERM PHRASE

Afebrile temperature is >if the patient

included in the is febrile,
monitoring support it with
sheet, status subjective and
can be deducted objective cues.
here
> evaluate
effectiveness of
nursing
intervention for
fever, include
the element of
time
 OBSOLETE REASON SUGGESTED
TERM PHRASE

due medication recording of >document

given/due meds medications medicines that
given given is in the were not given
medication and it's reason
sheet
>document
stat medicines
given, it's
indication and
evaluate the
effectiveness
 OBSOLETE REASON SUGGESTED
TERM PHRASE

seen at > it is expected > visit patient

intervals that we visit frequently
the patient at and assess for
intervals any
complications
 OBSOLETE REASON SUGGESTED
TERM PHRASE

needs attended/ > it is expected > visit patient

kept comfortable/ that we visit the frequently and
kept undisturbed/ patient at assess for any
kept safe intervals complications

 > it is expected > enumerate

that we make the measures done to
patient make the patient
comfortable comfortable
during their stay > verbalized needs
in the hospital must also be
documented and
referred to the
doctors as
necessary
 OBSOLETE REASON SUGGESTED
TERM PHRASE

slept fairly/ sleep > only noted if the > if the patient has
well/asleep the patient is having difficulty in
whole shift difficulty in sleeping;
sleeping document the
subjective cues,
interventions
done and
evaluation.
* Slept for
approximately 5
hours as
verbalized by
patient”
 OBSOLETE REASON SUGGESTED
TERM PHRASE

MGH > not an accepted > "patient seen by

abbreviation Dr. Gueco, with
discharge order
given"
 OBSOLETE REASON SUGGESTED
TERM PHRASE

no complaints > why document

made/ for further something that
management never happened
Forms Used in IV Therapy
Patient and Family Education Form
Forms Used in IV Therapy

Infusion Sheet
Forms Used in IV Therapy

PROGRESS NOTES
Charting System Formats

 Traditional narrative charting

 Problem-oriented medical record
system
 Problem-intervention-evaluation
system
 Focus charting
 Charting-by-exception system
 FACT system
 Core system
Traditional Narrative Charting
Advantages:
-Most flexible of all documentation
systems.
-Training time needed for new staff
members is brief.
-Other health care team members can
review the patient’s progress on a day-
to-day basis.
-Can easily present information collected
over an extended period.
-Helps to decrease charting time when
combined with other documentation
devices.
Traditional Narrative Charting
Disadvantages:
-You must read the entire record to arrive
at the outcome.
-Tracking problems and identifying trends
in patient’s progress can also be difficult
and time consuming.
-Tendency to document everything.
-Difficult to retrieve specific information.
-Some may be documented briefly, others
at length for no clear reason.
Traditional Narrative Charting
Problem-oriented Medical Record System
(SOAP, SOAPIE, SOAPIER)
Advantages:
-Organizes information about each
problem into specific categories.
-Illustrates continuity of care, unifying the
care plan and progress notes into a full
record.
-Promotes documentation of the nursing
process.
-Eliminates documentation of non-
essential data.
-Most effective in acute care or long-term
care settings.
Problem-oriented Medical Record System
(SOAP, SOAPIE, SOAPIER)
Disadvantages:
-Emphasis on the chronology of problems
rather than their priority.
-Repetitious charting of assessment
findings.
-Routine care may be undocumented
unless flow sheets are used.
-Difficulties may arise if team members
fail to update the problem list regularly.
Problem-oriented Medical Record System
(SOAP, SOAPIE, SOAPIER)
Disadvantages:
-The considerable time and cost of
training new personnel to use the
method may also be an disadvantage.
-Isn’t well suited for settings with rapid
patient turnover.
Problem-intervention-evaluation System

Advantages:
-Ensures that your documentation
includes nursing diagnosis, related
interventions, and evaluations.
-Encourages to meet JCAHO
requirements.
-Provides organizing framework for your
thoughts and writing.
-Simplifies documentation.
-Promotes continuity of care.
-Improves the quality of progress notes.
Problem-intervention-evaluation System

Disadvantages:
-May require in-depth training for staff
members.
-Re-evaluation of each problem during
each shift is time-consuming and leads to
repetitive entries.
-Omits documentation of the planning
step in the nursing process.
-Doesn’t incorporate multidisciplinary
charting.
 Assessment checklist
NURSING PROCESS • Physical
• Psycho-social
Progress Notes: • Mental-Spiritual
Focus charting • Environmental
GATHER DATA
W/ DAR Format • Diagnostic Results

• Vital signs, initial

EVALUATE
ANALYZE DATA * Maslow’s
Implementation Hierarcy
• Medication sheet * A.B.C.D.
• Vital signs sheet
IMPLEMENT PLAN
• I.V. fluids sheet
• I & O sheet
• Other special forms * Kardex
Four Elements of Focus Charting

 Focus GATHER DATA

 Data
EVALUATE
 Action ANALYZE DATA

 Response

IMPLEMENT PLAN
 Focus Charting

Advantages:
-Flexible and can be adapted to fit any
clinical setting.
-Centers on the nursing process.
-The format provides cue that direct
documentation in a process-oriented
way.
-Easy to find information on a particular
problem.
-Encourages regular documentation of
patient responses to medical and nursing
therapy.
 Focus Charting

Advantages:
-Ensures adherence to JCAHO
requirements.
-Can be used to document many topics
without being confined to those on the
problem list.
-Helps to organize your thoughts and
document succinctly and precisely.
 Focus Charting

Disadvantages:
-May require in-depth training, especially
for staff familiar with other systems.
-Requires you to use many flow sheets
and checklists.
-Can be a narrative note if you neglect to
include patient’s response to
interventions.
Charting-by-exception System

Advantages:
-Decreases the time needed to document
normal and abnormal findings.
-Promotes uniform nursing practice.
-Flow sheets lets you easily track trends.
-Abnormal findings are highlighted.
-Documentation of routine care is
eliminated.
-Information that has been recorded isn’t
repeated.
Charting-by-exception System

Disadvantages:
-Major time commitment needed to
develop clear guidelines and standards
of care.
-Doesn’t accommodate integrated or
multidisciplinary charting.
-May be questioned in court until the
system becomes more widely known.
 FACT System
Advantages:
-Eliminated repetition.
-Encourages consistent language and
structure.
-Outcome oriented.
-Communicates patient progress to all
health care team members.
-Permits immediate recording of current
data.
-Eliminates the need for many different
forms.
-Reduces the time spent writing narrative
notes.
 FACT System
Disdvantages:
-Requires major time commitment to
develop standards and implement the
system.
-Narrative notes may be too brief.
-Nurse’s perspective may be overlooked.
-The nursing process framework may be
difficult to identify.
 Core System
Advantages:
-Incorporates the entire nursing process
into one system.
-Groups nursing diagnosis and functional
assessment together, allowing various
solutions.
-Promotes concise documentation.
-Encourages the daily recording of
psychosocial information.
-Useful in acute care and long-term care
facilities.
 Core System
Disadvantages:
-May require in-depth training for staff
members who are familiar with other
systems.
-Developing forms may be costly and
time-consuming.
-Doesn’t always present information
chronologically.
-Progress notes may not always relate to
the care plan.
 WORKSHOP
DATE TIME NOTES
3/19/03 1600 P #1: Ineffective breathing pattern related to possible
smoke inhalation.----------------------------------------------------
I. P #1: Assessed respiratory rate and breath sounds q
h to R/O pulmonary edema and bronchospasm. Tought
pt. how to perform deep-breathing and coughing
exercises, and taught use of incentive spirometer. O2
applied 2 Ll min via nasal cannula.-----------------------------
---------------------------------------------------------------------------
EP #1: Pt. maintains patent airway and normal RR and
depth. Pt. understands the importance of performing
deep-breathing and coughing exercises q h. Pt. has
normal ABG levels--------------------------------------------------
--------------------------------------------------Deborah Ryan, RN
 WORKSHOP
DATE TIME NOTES
3/19/03 1600 P #2: Decreased cardiac output R/T reduced stroke
volume as a result of fluid loss through burns.---------------
I.P#2: Teach pt. to report any restlessness, diaphoresis,
or light headedness, which may indicate shock.
Evaluate VS and hemodynamic readings at least q 2 hr.
Monitor urine output q h. Monitor ABG levels. Provide
and monitor I.V. therapy.-------------------------------------------

EP#2: Pt. maintains normal VS and stable hemodynamic

status. ABGs WNL. Pt. has adequate urine output. Pt.
verbalizes signs and symptoms of shock. Pt. receiving
adequate replacement through I.V. therapy------------------
--------------------------------------------------Deborah Ryan, RN
 WORKSHOP
DATE TIME NOTES

3/19/03 1630 P #3: Acute pain related to second-degree

burns over 20% of body.---------------------------
IP#3: Assess pain q 2 hr and medicate q 3
to 4 hr with morphine, as ordered.--------------

EP#3: Pt. reports a decrease in pain rating

from 8 to 2 on a scale of 1 to 10 being the
worst pain imaginable------------------------------
---------------------------------Deborah Ryan, RN