Category: Education

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DOCUMENTATION & REPORTING Conducted by: Ms.Monika (clinical instructor) Army College of Nursing

Documentation :

Documentation It is the process of communicating in written form about essential facts for the maintenance of continuous history of events over a period of time. Record is the permanent written communication that documents information relevant to a client’s health care management.

Reports :

Reports Reports are oral or written exchange of information shared between nurses or a no. Of persons. Reporting is communication of information to another individual.


Purposes 1 .Communication : important purpose of documentation is to communicate information among health care workers. It is an account of client’s history, present health status, treatment & response to treatment.


Contd….. 2. It helps in providing comprehnsive nursing care. 3. Legal record: documentation protect client as well as workers, every client has right to inform & access information on chart.It is invaluable for checking mal- practice, also in case of MLC cases. 4. Education: one of the purpose is to educate/ teach client, medical students. client’s records are used by all disciplines in teaching rounds.

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5. Research: documentation means written evidence, research also needs evidence. 6. Audit: it is a way of reviewing records for purpose of collecting data. Purpose of auditing is to check quality of care provided, it can be done only if we have written proof.

Guidelines: reporting :

Guidelines: reporting Ligibility : information must be easily readable, without any error. In case of any mistake, draw one underline through errorneos entry & state reason for error, never forget to do initials & date of correction. Accurate: accuracy is very important, use medical terminology with correct spellings


Contd…. E.g. incorrect: client took one glass of water correct: client took 250 ml of water Completeness : always make complete sentences, never leave space in between lines,avoid using abbrebiations or symbols. Currentness : keep documents upto date, if any change occurs it must be written immediately.


Contd… Organised : start any entry with hospiatl name, patient name, CR no., gender, diagnosis, date & time. Write in chronological order. Confidentiality : all clients information should be kept confidential. Factual: document findings with supportive factual data.

Methods of recording:

Methods of recording Narrative charting Source oriented charting Problem oriented charting PIE charting Focus charting Charting by exception


Contd…. Narrative charting : traditional method, a story format: describes client’s status, interventions, treatment. Replaced because of time consuming, difficulty in retrieving data & disorganization in flow of care Source oriented charting : descriptive recording done by each mamber of health care team on separate records.


Contd…. Problem oriented charting : places emphasis on client’s problem, each member contributes to a single list of identified client problems. PIE chart : problem, intervention, evaluation. client’s problems are labeled & numbered, when interventions are implemented, problem no. Is identified, it incorporates ongoing plan of care into daily documentation.


Contd…. Focus charting : method of identifying & organizing narrative documentation. It include data, action & response. Charting by exception: requires nurse to record only deviations from prescribed norms, established to overcome recurring problems of lengthly, repititive notes.

Reporting :

Reporting It is the verbal or written communication of data regarding client’s health status needs, treatments, outcomes & responses. It facilities clinical decision making, continuity of care & coordination.

Types :

Types Change of shift report : on duty nurse summarize information about assigned client, to provide continuity of care Transfer report: such reporting is done in case client is transferred from one ward to another to receive different level of care, may be given on phone or in person


Contd…. Incident report : used to document any unusual occurrence or accident in delivery of client care Such as client falls, medication error, needle stick injury. Points to be written: record date, time & place, describe what happened, do not interpret. Submit as soon as possible.

Importance of records & reports:

Importance of records & reports 1.Decision making 2. Planning client care 3. Communication 4. Legal documentation 5.Education & 6.Research 7. Auditing 8.Quality assurance monitoring 9.Vital statistics & 10. financial billing 11. Accrediting & licensing

record writing : Principles :

record writing : Principles Record should be written clearly, accurately, appropriately & legibly All entries should be signed Do not make any error Write in chronological order Write continuously with no blank space


Contd… Each page of records should be properly identified with name, age. Bed no. Ward etc. Use only standard abbreviations It should be truthful, brief & complete

Care of records:

Care of records Records are kept under safe custody No individual sheet is separated from complete record Records are kept in place, not accessible to pt. No stranger is allowed to read records All records are to be arranged according to hospital rules, may be in alphabetically, numerically, with index cards. It should never be sent out of hospital.

Types of records:

Types of records Ward records Nurse’s records Students records Staff records Academic & administrative records

Ward records:

Ward records Patient’s clinical record Instruction book, round register, attendance register, drug maintenance register Admission record & discharge record Census record Call book, complaint book Visitors record Indent book, stock & issue register Treatment record & death register

Medical/ nurse’s records:

Medical/ nurse’s records Nurse’s assessment sheet Change of shift record Standardized care plan Nurse’s report book Nurse’s progress notes Treatment chart Graphic sheet

Student records:

Student records Application forms Admission register Cummulative health record Class attendance & leave record Clinical & field experience, student rotation Internal assessment register, mark list Record of CCA Student evaluation

Staff records:

Staff records Application forms Copy of letter of appointment Job descriptions Record of staff members Periodic evaluation of progress report Leave record Health record

Academic/administrative records:

Academic/administrative records Philosophy, purposes & curriculum Course content & course plan Record of academic requirements Rotation plans Record of committees Record of stocks Affiliation records


Contd…. Annual reports Written policies Copy of brochure Inspection record Photograph/video of important events Computerized records

Communication within health care team:

Communication within health care team Human being is a social animal. To socialize with others, we need to share over views, beliefs, feelings etc. This sharing is facilitated by communication. In medical field also, communication with members of health team is very important, it facilitates process of patient care.

Importance within health team:

Importance within health team As every member gathers different information, it helps in planning comprehensive quality care. Sharing information helps to verify clues, thus reduces ambiguity Avoids duplication of efforts in collecting data It ensures coordination between health team members

Communication media:

Communication media Media is a way by which information is shared. Commonly used in medical field are: Reports Consultation Referrals Patient round

Reports :

Reports Reporting is a means of sharing the brief information about the event that recently occured It can be done verbally or written It is also used to alert members for care of specific patients e.g. urine out put of client of ARF. GCS of immediate post operative client

Consultation :

Consultation It means taking the opinion of some specialist Nurses consult peers, incharge nurse, physician, specialized nurse regarding client’s care plan Referrals : it involves requesting services of another department within agency or referring a client to another agency It assures continuity of care, it is the responsibility of nurse to assure that referral form is filled & complete

Patient round:

Patient round It is the best way of communicating information about client Nurses make round with incharge nurse During round information is exchanged, views & suggestions are taken regarding client’s progress & plans are discussed for care

Computerized documentation:

Computerized documentation Nurses are using computerized system for suppies, equipment, stock medications & diagnostic testing Computer facilities: speed in communication, accuracy in information, capacity of information storage, data retrieval & data revision

Advantages :

Advantages It enhances systematic approach to client care through standardized protocols, teaching documents It facilitates fast communication It is cost effective Increases quality of documentation Saves documentation time by avoiding duplication of effort

Disadvantages :

Disadvantages Costly installation of computer software. Problem in protecting client’s confidentiality. Transition to computerized documentation presents both opportunities & challanges to nurses. Mostly practitioners are reluctant to change from comfortable pen & peapet methods to advanced electronic system.

Minimize legal liabilities:

Minimize legal liabilities In order to minimize legal liabilities, document should have following characteristics: Factual, accurate, complete, legible, logically organized Client’s identifying information must be written on each page of client’s record Nurse should never edit or delete documentation done by other personnel


Contd… At end of nursing notes, line can be drawn from end of text to end of right margin on line so that no one else can add documentation Documents must be signed by nurse at end of entry Never leave empty space between entries As client has right to inform, every procedure must be explained to client, written consent should be taken before operations.

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