unit 6 documentation and reporting

1. Documentation and
reporting
Unit- VI
Mr. gulamahmad raza
Nursing tutor

2. Documentation
 Documentation is anything written or
electronically generated that describes the
status of a client or the care or services given to
that client. (Perry, A.G., Potter, P.A., 2010).
 “Client” refers to individuals, families, groups,
populations or entire communities who require
nursing expertise.
 Documentation serves as a permanent record of
client information and care.

3. Purposes of Documentation
 Provides a written record of the history,
treatment, care, and response of the patient
while under the care of a health care
provider.
 Is a guide for reimbursement of costs of
care.
 May serve as evidence of care in a court of
law.

4.  Shows the use of the nursing process.
 Provides data for quality assurance studies.
 Is a legal record that can be used as evidence
of events that occurred or treatments given.
 Contains observations by the nurses about
the patient’s condition, care, and treatment
delivered.
 Shows progress toward expected outcomes.

5. Principles ofDocumentation
1. DATE and TIME
 Document date and time of each recording.
 Record time in conventional manner.
 Example: 8 am to 2 pm etc. this is important
not only due to legal reasons but also for
the client’s safety.

6. 2.LEGIBILITY
 Entries must be legible and easy to read.
 Writing must be clear.
 Very important in recording numbers and
medical terms.

7. 3.CORRECT SPELLING
 Correct spelling is essential for accuracy.
 If unsure about the spelling use a dictionary
or other resource book.

8. 4.PERMANANCE
 Entries should be done in dark ink. It helps
to identify changes and allows duplication
(Xerox).

9. 5. ACCURATE
 Use of exact measurement establishes accuracy.
E.g. Intake 450ml of water than writing adequate
amount of water.
 Clients name and identifying information is written
on each page.
 Before making any entry in the chart make sure that
it is correct.
 Chart only your observations and actions to be
accountable.

10. 6.SEQUENCE
 Document events in order of occurrence.
 Eg. Record assessments, then nursing
interventions and then the client responses.
 Update or delete problems as needed.

11. 7. APPROPRIATENESS
 Record informations pertaining to the client
health problems & care only.
 Avoid personal informations that are in
appropriate.

12. 8. COMPLETENESS
 Document all necessary informations.
 It should give a clear picture of what took
place.
 Complete pertinent assessment data such
as vital signs, wound drainage, client
complaints, who was notified and what
interventions are carried out etc. are
recorded.

13. The following informations should be
includedin the chart:
 A new or changed information
 Signs and symptoms
 Client behavior
 Nursing interventions
 Medications
 Physician’s orders carried out
 Client teaching
 Client response

14. 9. CONCISENESS (BRIEVITY)
 Recording need to be brief as well as
complete to save time in communication.
 Client’s name and the word client can be
omitted.
 Eg. “perspiring profusely.
 Use accept abbreviations.

15. 10. ORGANIZED
 Information should have logical manner
 Eg. description of pain, nurses assessment
and interventions and the client response.
 This helps in preventing any omission of
informations.
 Easy to read.

16. 11. SIGNATURE
 Each recording is signed by the nurse.
 Signature includes the name and the title
 In computerized charting nurse will have his
or her own code.

17. 12.CONFIDENTIALITY
 All the client’s record are confidential files
 The information in the chart is personal as
well as legal.
 Record shouldn't be copied without the
permission of the client.
 Nurse should not allow any outsiders to
verify the client record.

18. Record
Definition
 Record is formally legal, administrative tool
that permanently document information
relevant to direct or indirect patient care.
Records are administrative devices used to
collect and classified information.

19.  A record is a permanent written
communication that documents information
relevant to a client’s health care management.
 A record is a clinical, scientific, administrative
and legal document relating to the nursing
care given to the individual family or
community.
 Reports are oral or written exchanges of
information shared between caregivers or
workers in a number of ways.

20. Purposes of Records
 Supply data that are essential for programme
planning and evaluation.
 Provide the practitioner with data required
for the application of professional services
for the improvement of family's health.
 Tools of communication between health
workers, the family & other development
personnel.

21.  Effective health records show the health
problem in the family and other factors that
affect health.
 Indicates plans for future.
 Help in the research for improvement of
nursing care.
 It provides baseline data to estimate the
long-term changes related to services.

22. PURPOSE OF KEEPING RECORDS
 Communication
 Aids to diagnosis
 Education
 Documentation of continuity
 Research
 Legal documentation
 Individual case study

23. Characteristics of good recording
and reporting
Accuracy
Confidentiality
Consciousness
Thoroughness
Up to date
Organization
Objectivity

24. Principles ofrecord writing
 Nurses should develop their own method of
expression and form in record writing.
 Written clearly, appropriately and adequately.
 Contain facts based on observation,
conversation and action.
 Select relevant facts and the recording should
be neat, complete and uniform.

25.  Valuable legal documents and so it should be
handled carefully, and accounted for.
 Records should be written immediately after
an interview.
 Records are confidential documents.
 Accurately dated, timed and signed.
 Not include abbreviations, jargon,
meaningless phrases.

26. Importance ofRecords in Hospital
For the IndividualandFamily
 Records serve to document the history of the
client.
 Records assist in the continuity of care.
 Records serve as evidence to support or to
manage or face the legal questions that arise.
 Records serve to recognize the health needs and
can be used as a research and teaching tool.

27. For the Doctor
 Serves as guide for diagnosis, treatment,
follow up and evaluation of services.
 Indicate progress and continuity of care.
 Help self evaluation of medical practice.
 Protect the doctor in case of legal issues.
Records may be used for teaching and
research.

28. For the Nurse
 Provide with documentation of services
rendered, i.e. shows health condition of the
client.
 Provide data essential for planning and
evaluation of services for further
improvement.
 Serve as a guide for professional growth.
 Enable to judge the quality and quantity of
work done.
 Serve as communication tool between staff
and other members involved in care.
 Indicate plans for the future.

29. ForAuthorities
 Provide the management with statistical
information necessary for decision in regard
to utilization of resources, planning for
administrative control and future references.
 Help the supervisor evaluate the services
rendered, teaching done and a person’s
action and reactions.

30. TYPES OF RECORDS
1. Patients clinical record
2. Individual staff records
3. Ward records
4. Administrative records with educational
value.

31. PATIENTS CLINICAL RECORDS
 It is the knowledge of events in the patient illness,
progress in his or her recovery and the type of care
given by the hospital personnel.
 a) Scientific and legal.
 b) Evidence to the patient the his /her case is
intelligently managed.
 c) Avoids duplication of work.
 d) Information for medical and legal nursing
research.
 e) Aids in the promotion of health and care.
 f) Legal protection to the hospital doctor and the
nurse.

32. INDIVIDUAL STAFF RECORDS
A separate set of record is needed
for staff, giving details of their sickness
and absences, their carrier and
development activities and a personnel
note.

33. WARD RECORDS
 Reducting or increase in beds.
 Change in medical staff and non
nursing personnel for the ward.
 The introduction and pattern of
support.

34. ADMINISTRATIVE RECORDS WITH
EDUCATIONAL VALUE
 Treatments.
 Admissions.
 Equipments losses and replacements.
 Personnel performance.
 Other administrative records

35. 1) Cumulative or continuing records
This is found to be time saving,
economical and also it is helpful to
review the total history of an individual
and evaluate the progress of a long
period.

36. 2) Family records
 All records, which relate to members of family,
should be placed in a single family folder. Gives
the picture of the total services and helps to
give effective, economic service to the family as
a whole.
 Separate record forms may be needed for
different types of service such as TB, maternity
etc. all such individual records which relate to
members of one family should be placed in a
single family folder.

37. REPORTS
Reports can be compiled daily, weekly,
monthly, quarterly and annually. Report
summarizes the services of the nurse and/ or the
agency. Reports may be in the form of an analysis
of some aspect of a service. These are based on
records and registers and so it is relevant for the
nurses to maintain the records regarding their
daily case load, service load and activities.

38. Definition
 Reports are information about a patient either
written or oral. (Sr. Nancy)
 A report is a summary of activities or
observations seen, performed or heard.
(Potter and Perry)
 Reports are oral or written exchanges of
information shared between care givers of
workers in a number of ways. A report
summarises the service of the personnel and of
the agency. [ Jean b. 2002 ]

39. PURPOSES
 Report is an essential tool to communication
 To show the kind and amount of services
rendered over a specific period.
 To illustrate progress in teaching goals.
 As an aid in studying health condition.
 As an aid in planning.
 To interpret the services to the public and to
the other interested agencies.

40. TYPES OF REPORT
 ORAL REPORTS
 WRITTEN REPORTS

41. ORAL REPORTS
Oral reports are given when the
information is for immediate use and not for
permanency.
WRITTEN REPORTS
Written reports are to be written when
the information to be used by several
personnel which is more or less of permanent.

42. TYPES OF REPORTS IN NURSING
Commonly used reporting in nursing.
1. Change-of-shift reports (CSR)
2. Transfer reports
3. Incident reports
4. Telephone reports

43. CHANGE-OF-SHIFT REPORTS(CSR))
 This type of reporting most commonly
using.
 At the end of each shift nurses report
information about their assigned client’s to
the nurses working on the next shift.
 The report provides continuity of nursing
care among nurses who are caring for a
client.

44. EXAMPLE FOR CSR
If first shift nurse finds a certain pain
relief measure effective for a client, it is
essential that the information be related to
the next nurse caring for the client so that
pain control intervention can be continued.

45. GUIDELINES FOR GOODCSR
 Provide only essential background data on
patient (e.g. name, age, gender, Medical
diagnosis, and history)
 Describe objective measurements about patient
condition an response of health problem.
 Evaluate results of nursing or medical care
measures.

46.  Be clear on priorities to which oncoming staff
must attend.
 Don’t review all routine care and procedure or
tasks.
 Don’t review all biographical data already
available in written form.
 Don’t use critical comments of patient behavior.

47. TRANSFER REPORTS
Patient’s are often Transfer from one
unit to another to receive different levels of
care and treatment.
E.g. client’s transfer from an ICU or
critical care units to general nursing units
when the client stable or no longer requires
such intense monitoring.

48. WHEN A GIVING A TRANSFER REPORts, THE
FOLLOWING INFORMATION SHOULD BE
GIVEN:-
 Patient name, age, primary Physician and
Medical diagnosis.
 Brief summary of progress up to the time of
transfer.
 Patient health status (physical &
psychological).
 Allergies (regarding drugs and medications).

49.  Current treatment status (IV fluids, blood
transmission any other).
 Current nursing diagnosis or problem and care
plan.
 Patient current vital sings and heamodynamic
status (Temp., BP HR, RR, SpO2, ECG etc.).
 Any critical assessment or procedure
performed before going to transfer a client.
 Need for any special equipment (Cardiac
monitoring, suction equipment etc.).

50. INCIDENT OR OCCURRENCE
REPORTS
 An incident is any event that is not consistent
with the routine operation of health care unit.
 Incidents are commonly occur when patient
under care within hospital settings.
 Incident reports are in major part of a unit
quality improvement program.

51. TYPE OF INCIDENTS
 Falling from bed or in toilet.
 Needle stick injuries.
 Burns (hot Application or from other
sources).
 Drugs or medications administration errors.
 Misidentification of patient.
 Accidental omission of ordered therapies.

52. GUIDELINES TO REPORTINCIDENT
 Describe in concise what exactly happens especially in
objective terms.
 Enumerate incident unit, time etc.
 Explain patient condition before and after the incident
(physical & psychological).
 Describe any treatment is given after incident.
 Record patient vital sings after incident.
 No nurse should blamed in an incident reports.
 As possible soon submit a report to the authority.

53. TELEPHONE REPORTS
 Nurse’s inform Physician or other health care team
members regarding changes in patient condition
during caring and communicate information to
nurses on other units about client’s Transfer.
 Telephone reports also can be utilizes a laboratory
staff or other radiological staff to providing
immediate results about patient.
 Telephone reports must contain clear, accurate,
and concise.

54. GUIDELINES FOR TELEPHONE
REPORTS
 It should be clearly patient name, room, unit
no, IP number and diagnosis.
 Repeat the reports any communication error
occur.
 Use clarification questions to avoid
misunderstanding.

55. COMMON RECORD-KEEPING FORMS
 A variety of paper or electronic forms are
available for the type of information nurses
routinely document.
 The categories within a form are usually
derived from institutional standards of
practice or guidelines established by
accrediting agencies.

56. Admission Nursing History Forms
 A nurse completes a nursing history form
when a patient is admitted to a nursing unit.
 The form guides the nurse through a
complete assessment to identify relevant
nursing diagnoses or problems.

57. Flow Sheets and Graphic Records
 Flow sheets allow you to quickly and easily enter
assessment data about a patient, including vital signs and
routine repetitive care such as hygiene measures,
ambulation, meals, weights, and safety and restraint checks.
 Flow sheets help team members quickly see patient trends
over time and decrease time spent on writing narrative
notes.
 Critical and acute care units commonly use flow sheets for
all types of physiological data.

58. Patient Care Summary orKardex
 Kardex forms have an activity and treatment
section and a nursing care plan section that
organize information for quick reference.
 An updated Kardex eliminates the need for
repeated referral to the chart for routine
information throughout the day.

59. The patient caresummaryor Kardexincludes
the following information:
 Basic demographic data (e.g., age, religion)
 Health care provider’s name
 Primary medical diagnosis
 Medical and surgical history
 Current orders from health care provider (e.g. dressing
changes, ambulation, glucose monitoring)
 Nursing care plan
 Nursing orders (e.g., education sessions, symptom relief
measures, counseling)
 Scheduled tests and procedures
 Allergies.

60. Standardized Care Plans
 Some institutions use standardized care plans. The
plans, based on the institution’s standards of nursing
practice, are pre-printed, established guidelines used
to care for patients who have similar health
problems.
 After completing a nursing assessment, the nurse
identifies the standard care plans that are appropriate
for the patient and places the plans in his or her
medical record. The nurse modifies the plans to
individualize the therapies.

61. Progress Notes
 Progress notes made by nurses provide
information about the progress a client is
making toward achieving desired outcomes.

63. Discharge Summary Forms
 When you leave hospital, you should have a
discharge summary given to you.
 A discharge summary is a letter written by
the doctor caring for you in hospital.

64. It contains important information about your
hospital visit, Including:
 Why you came into hospital
 The results of any tests you had
 The treatment you received
 Any changes to your medication
 What follow-up you need

66. Most CommonDocumentsIn Patient
Record:
 Admission sheet
 Physician’s order
sheet
 Nurse’s admission
assessment
 Graphic sheet and
flow sheet- vital signs,
I/O chart
 Medical history and
examination
 Nurses’ notes
 Medication records
 Progress notes
 Results from
diagnostic tests
 consent forms
 Discharge summary
 Referral summary

67. Computerized documentation
Nurses use computers to store the
client’s database, add new data, create and
revise care plans, and document client
progress.

68. ADVANTAGES
 Increases the quality of documentation and
save time.
 Increases legibility and accuracy.
 Facilitates statistical analysis of data.
 The system links various sources of client
information.

69. DISADVANTAGES
 Client’s privacy may be infringed on if
security measures are not used.
 Breakdowns make information temporarily
unavailable.
 The system is expensive.
 Extended training periods may be required
when a new or updated system is installed.

70. PRECAUTIONS
 Password:- Never share, Change frequently.
 Make sure terminal cannot be viewed by
unauthorized persons.

71. Guidelines for reporting
1. FACTUAL BASIS
2. ACCURACY
3. COMPLETENESS
4. CURRENTNESS
5. ORGANIZATION
6. CONFIDENTIALITY

72. 1. FACTUAL BASIS:- Information about
clients and their care must be functional. A
record should contain descriptive,
objective information about what a nurse
sees, hears, feels and smells.
2. ACCURACY:- A client record must be
reliable. Information must be accurate so
that health team members have confidence
in it.

73. 3. COMPLETENESS:- The information within a
recorded entry or a report should be complete,
containing concise and thorough information
about a client care or any event or happening
taking place in the jurisdiction of manger.
4. CURRENTNESS:- Delays in recording or
reporting can result in serious omissions and
untimely delays for medical care or action
legally, a late entry in a chart may be interpreted
on negligence.

74. 5. ORGANIZATION:- The nurse or nurse
manager communicates information in a
logical format or order. Health team
members understand information better
when it is given in the order in which it is
occurred.
6. ONFIDENTIALITY:- Nurses are legally and
ethically obligated to keep information
about client’s illnesses and treatments
confidential.

75. COMMUNICATION WITH IN THE HEALTH
CARE TEAM
 In today’s health care system, delivery processes
involve numerous interfaces and patient handoffs
among multiple health care practitioners with
varying levels of educational and occupational
training.
 During the course of a 4-day hospital stay, a patient
may interact with different professionals, including
physicians, nurses, technicians, and others.

76.  Lack of communication creates situations
where medical errors can occur. These
errors have the potential to cause severe
injury or unexpected patient death.
 Effective communication takes place along
two approaches:
1. Recording
2. Reporting

77.  Patient identification and demographic data
 Informed consent for treatment and
procedures
 Admission data
 Nursing diagnosis or nursing care plan
 Record of nursing care treatment and
evaluation
 Medical history
 All records contain the following information:

78.  Medical diagnosis
 Therapeutic orders
 Medical and health discipline progress
notes
 Physical assessment findings
 Diagnostic study results
 Patient education
 Summary of operative procedures
 Discharge plan and summary

79.  Reports are oral, written, or audio taped
exchanges of information among caregivers.
 Common reports given by nurses include
change-of- shift reports, telephone reports, hand-
off reports, and incident reports.
 A health care provider calls a nursing unit to
receive a verbal report on a patient’s condition.
 The laboratory submits a written report providing
the results of diagnostic tests and often notifies
the nurse by telephone if results are critical.

80.  Team members communicate information
through discussions or conferences.
 For example, a discharge planning
conference involves members of all
disciplines (e.g., nursing, social work,
dietary, medicine, and physical therapy) who
meet to discuss the patient’s progress
toward established discharge goals.

81. Methods of recording/documentation
systems
 There are several documentation systems
for recording patient data.
 Regardless whether documentation is
entered electronically or on paper, each
health care agency selects a documentation
system that reflects its philosophy of
nursing.

82. Methods of recording
1. Narrative Charting
2. Source-Oriented
Charting
3. Problem-Oriented
Charting
4. PIE Charting
5. Focus Charting
6. Charting by
Exception (CBE)
7. Computerized
Documentation
8. Case Management
with Critical Paths

83. 1. Narrative Charting (TRADITIONAL
CLIENTRECORD)
 Describes the client’s status, interventions
and treatments, response to treatments is in
story format.
 Narrative charting is now being replaced by
other formats.

84. Five Basic componentsof aTraditional
Client Record
 Admission sheet
 Physician’s order sheet
 Medical history
 Nurse’s notes
 Special records and reports (referrals, X-ray,
reports, laboratory findings, report of surgery,
anesthesia record, flow sheets, vital signs, I&O,
medication.

85. 2. Source-OrientedCharting
 Each person or department makes notations in
a separate section/s of the client’s chart.
 Narrative recording by each member (source)
of the health care team on separate records.
 Most Traditional
 Different disciplines chart on separate forms
 Each reader must consult various parts of the
record to get a complete picture
 Records become bulky
 For example the admission department has an
admission sheet, nurses use the nurses notes,
physicians have a physician notes, etc.

86. 3. Problem-Oriented MedicalRecord(
POMR)/(SOAP/IEr format)
Uses a structured, logical format called
S.O.A.P./I.E.R
 S – Subjective. What patient tells you.
 O – Objective. What you observe, see.
 A – Assessment. What you think is going on
based on your data.
 P – Plan. What you are going to do.

87. NURSINGPROCESS
 I – Intervention (specific interventions
implemented)
 E – Evaluation. Patient response to
interventions.
 R – Revision. Changes in treatment.
 Uses flow sheets to record routine care.
 SOAP entries are usually made at least every
24 hours on any unresolved problem.

88. 4. PIECharting
 P: Problem statement
 I: Intervention
 E: Evaluation
Example:
 P: Patient reports pain at surgical incision as
7/10 on 0 to 10 scale
 I : Given morphine 1mg IV at 10:35 am.
 E : Patient reports pain as 1/10 at 10:55 am.

89. Pain scale

90. 5.FocusCharting (DAR)
 A method of identifying and organizing the
narrative documentation of all client concerns.
 Uses a columnar format within the progress
notes to distinguish the entry from other
recordings in the narrative notes (Date & Time,
Focus, Progress note).

91.  DATA – Subjective or objective that supports the
focus (concern)
 ACTION – Nursing intervention
 RESPONSE – Patient Response to intervention
Example:
 D – Complaining of pain at incision site, pain scale:
7/10
 A – Repositioned for comfort. Demerol 50 Mg IM
given.
 R – States a decrease in pain, “feels much better.”

92. 6. Charting by Exception(CBE)
 The nurse documents only deviations from
pre-established norms (document only
abnormal or significant findings).
 Avoids lengthy, repetitive notes.

93. 7. ComputerizedDocumentation
 Increases the quality of documentation and
save time.
 Increases legibility and accuracy.
 Facilitates statistical analysis of data.

94. 8. CaseManagementProcess
 A methodology for organizing client care
through an illness, using a critical pathway.
 A critical pathway is a multidisciplinary plan
or tool that specifies assessments,
interventions, treatments and outcomes of
health related problems a cross a time line.

95. Minimizing Legal Liability Through Effective Record
Keeping
As the records are the proof of care and
legal documents the records have to be
maintained appropriately to avoid legal
complications.

96. The nurse has to take the following measures:
 Keep the records under safe custody of
nurses.
 No individual sheet should be separated.
 Maintain the confidentiality of the
information
 Don’t make accessible to other patients and
visitors.

97.  Strangers are not permitted to read records.
 Records are not handed over to the legal
advisors without written permission of the
administration.
 Handed carefully, not destroyed.
 Identified with bio-data of the patients such as
name , age, admission number, diagnosis, etc.
 Never sent outside of the hospital without the
written administrative permission.

98.  Send the records to medical record
department (MRD) for the further usage.
 You spill something on the chart, do not
discard notes. Recopy, put original and copied
sheets in chart. Write “copied” on copy.
 Do not scribble out charting.
 Follow your facilities policy.
 Do not alter charting, it is a legal document.

99. Maintenance Of ComputerizedRecords:
 Maintain the confidentiality of the
information.
 Never disclose the password to any others
 Don’t delete any information from the
system unless you are authorized to do.

100. THANK YOU