Recording and reporting in nursing

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RECORDING AND REPORTING IN NURSING:

RECORDING AND REPORTING IN NURSING Mr. S. Paramathma

Documentation :

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 number Of persons. Reporting is communication of information to another individual.

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Ethical and legal considerations “The nurse has a duty to maintain confidentiality of all patient information” (ANA code of ethics 2001). The records are used in client conferences, clinics, rounds, client studies, and written papers. It is the responsibility of the student or health professional to protect the client’s privacy by not using a name or any statements in the notations that would identify the client.

Purposes of Client Records: :

Purposes of Client Records: 1- Communication … The record serves as the vehicle by which different health professionals who interact with a client communicate with each other. 2- Planning Client Care ……Each health professional uses data from the client’s record to plan care for that client. 3- Auditing Health agencies…… An audit is a review of client records for quality assurance purpose.

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4- Research…….. The information contained in a record can be a valuable source of data for research. The treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients. 5- Education ……. a record can frequently provide a comprehensive view of the client, illness, effective treatment strategies, and factors that affect the outcome of the illness.

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6- Reimbursement ……. for a facility to obtain payment through Medicare, the client’s clinical record must contain the correct diagnosis. 7- Legal Documentation …….The client’s record is a legal document and is usually admissible in a court as evidence. 8- Health Care Analysis ……. it assists health care planners to identify agency needs.

Others :

Others 9. Health service planning 10. Vital Statistic 11. Historical Documents 12. Diagnostic and therapeutic orders 13. Quality assurance

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General Guidelines for Recording Because the client’s record is a legal document and may be used to provide evidence in court, many factors are considered in recording: 1- Date and Time , document the date and time of each recording. This is essential not only for legal reasons but also for client safety. Accurate according to the 24-hours clock (military clock) or in the conventional manner (am, pm).

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2- Timing , follows the agency’s policy about the frequency of documenting, and adjusts the frequency as a client’s condition indicates. No recording should be done before providing nursing care. 3- Legibility , all entries must be legible and easy to read to prevent interpretation errors. 4- Permanence , all entries made in dark ink so that the record is permanent and changes can be identified.

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5- Correct Spelling , is essential for accuracy in recording. Incorrect spelling gives a negative impression to the reader and, thereby, decreases the nurse’s credibility. 6- Signature , each recording on the nursing notes is signed by the nurse making it. The signature includes the name and title. For example, SH.Qadous , RN.

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7- Accuracy , the client’s name and identifying information should be stamped or written on each page of the clinical records. Before making any entry, check that it is the correct chart. Do not identify charts by room number only, check the client’s name. Notations on records must be accurate and correct. Accurate notations consist of facts or observations rather than opinions or interpretation. It is more accurate, for example, to write that the client” refused medication” (fact) than to write that the client “was uncooperative” (opinion).

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When describing something, avoid general words, such as large ,good, or normal, for example, chart specific data such as “2cm* 3cm bruise” rather than ”large bruise”. When a recording mistake is made, draw a line through it and write the words mistaken entry above or next to the original entry, with your initials or name. Do not erase, or use correction fluid. Write on every line but never between lines.

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8- Sequence , document events in the order in which they occur, such as record assessments, then the nursing interventions, and then the client’s responses. Update or delete problems as needed. 9- Appropriateness , records only information that pertains to the client’s health problems and care. Recording irrelevant information may be considered an invasion of the client’s privacy. 10- Appropriateness , records only information that pertains to the client’s health problems and care. Recording irrelevant information may be considered an invasion of the client’s privacy.

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11- Completeness , not all data that a nurse obtains about a client can be recorded; however, the information that is recorded needs to be complete and helpful to the client and health care professionals. Nurse’s record need to reflect the nursing process, record assessment, dependent and independent nursing interventions, client problems, client comments and responses to interventions and tests, progress toward goals.

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12- Conciseness , recording need to be brief as well as complete to save time in communication. 13. Accepted Terminology, Use only commonly accepted abbreviations, symbols, and terms are specified by the agency. Many abbreviations are standard and used universally. 13- Legal Prudence , accurate, complete documentation should give legal protection to the nurse, the client’s other caregivers, the health care facility, and the client. “ Complete charting for example by using the steps of the nursing process as a framework, is the best defense against malpractice .”

VALUES AND USES OF RECORDS :

VALUES AND USES OF RECORDS Record provides basic facts for services. Records show the health condition as it is and as the patient and family accepts it. Provides a basis for analyzing needs in terms of what has been done, what is being done, what is to be done and the goals towards which means are to be directed. Provides a basis for short and long term planning. It prevents duplication of services and helps follow up services effectively.

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Helps the nurse to evaluate the care and the teaching which she has given. It helps the nurse organize her work in an orderly way and to make an effective use of time. It serves as a guide to professional growth. It enables the nurse to judge the quality and quantity of work done. Records help them to become aware of and to recognize their health needs. A Record can be used as a teaching tool too. Record serves as a guide for diagnosis, treatment and evaluation of services. It indicates progress

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It may be used in research The record helps identify families needing service and those prepared to accept help. It enables him to draw the nurse’s attention towards any pertinent observation he has made. The record helps the supervisor evaluate the services rendered, teaching done and a person’s actins and reactions. It helps in the guidance of staff and students – when planned records are utilized as an evaluation tool during conferences.

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It helps the administrator assess the health assets and needs of the village or area. It helps in making studies for research, for legislative action and for planning budget. It is legal evidence of the services rendered by each worker. It provides a justification for expenditure of funds

TYPES OF RECORDS :

TYPES OF RECORDS 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. (e.g.) child’s record should provide space for newborn, infant and preschool data. The system of using one record for home and clinic services in which home visits are recorded in blue and clinic visit in red ink helps coordinate the services and saves the time

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2)   Family records The basic unit of service is the family. All records, which relate to members of family, should be placed in a single family folder. This 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

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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: Nurse’s assessment sheet Change of shift record Standardized care plan Nurse’s report book Nurse’s progress notes Treatment chart Graphic sheet

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

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Academic/administrative records: Philosophy, purposes & curriculum Course content & course plan Record of academic requirements Rotation plans Record of committees Record of stocks Affiliation records Annual reports Written policies Copy of brochure Inspection record Photograph/video of important events Computerized records

Types of entries:

Types of entries Admission notes Change of shift notes Assessment notes Interval or progress notes Transfer and discharge notes Client teaching notes Description of observation Symptoms and complaints Dressing, tube and or attached devices Medications and treatments Observation and psychosocial status ADL Valuables

Documentation Methods:

Documentation Methods 1. FOCUS CHARTING With this method of documentation, the nurse identifies a “focus” based on client concerns or behaviours determined during the assessment. For example, a focus could reflect: A current client concern or behaviour, such as decreased urinary output. A change in a client’s condition or behavior, such as disorientation to time, place and person. A significant event in the client’s treatment, such as return from surgery. In focus charting, the assessment of client status, the interventions carried out and the impact of the interventions on client outcomes are organized under the headings of data, action and response.

SOAP/SOAPIE(R) CHARTING :

SOAP/SOAPIE(R) CHARTING SOAP/SOAPIER charting is a problem-oriented approach to documentation whereby the nurse identifies and lists client problems; documentation then follows according to the identified problems. Documentation is generally organized according to the following headings: S = subjective data (e.g., how does the client feel?) O = objective data (e.g., results of the physical exam, relevant vital signs) A = assessment (e.g., what is the client’s status?) P = plan (e.g., does the plan stay the same? is a change needed?) I = intervention (e.g., what occurred? what did the nurse do?) E = evaluation (e.g., what is the client outcome following the intervention?) R = revision (e.g., what changes are needed to the care plan?) Similar to focus charting, flow sheets and checklists are frequently used as an adjunct to document routine and ongoing assessments and observations.

NARRATIVE CHARTING :

NARRATIVE CHARTING Narrative charting is a method in which nursing interventions and the impact of these interventions on client outcomes are recorded in chronological order covering a specific time frame. Data is recorded in the progress notes, often without an organizing framework. Narrative charting may stand alone or it may be complemented by other tools, such as flow sheets and checklists.

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Reporting The purpose of reporting is to communicate specific information to a person or group of people. Change-of–shift Reports, is a report given to all nurses on the next shift. Its purpose is to provide continuity of care for clients by providing the new caregivers a quick summary of client needs and details of care to be given.

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Telephone Reports , health professionals frequently about a client by telephone. Nurses inform primary care providers about a change in a client’s condition. - The nurse receiving a telephone report should document the date and the time, the name of the person giving the information, and the subject of the information received. - The person receiving the information should repeat it back to the sender to ensure accuracy.

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- When giving a telephone report to a primary care provider, begin with name and relationship to the client. For example “This is Maher Battat, RN, I’m calling about your client, Shamsa Mendes. I’m her nurse on the 7pm to 7am shift’’. - Telephone reports usually include the client’s name and medical diagnosis,…ect. The nurse should have the client’s chart ready to give any further information.

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Telephone Orders, physicians often order a therapy for a client by telephone. While the primary care provider gives the order, write the complete order down and read it back to ensure accuracy. Question about any order that is ambiguous, unusual, or contraindicated by the client’s condition.

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Nursing Rounds, procedures done to: - Obtain information that will help plan nursing care - Provide clients the opportunity to discuss their care - Evaluate the nursing care the client has received. During rounds, the nurse assigned to the client provides a brief summary of the client’s nursing needs and interventions being implemented.

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Incident Reports, or occurrence reports, are used to document any unusual occurrence or accident in the delivery of client care, such as falls or medication errors. These reports are used for quality improvement and should not be used for disciplinary action against staff members. Incident reports improve the management and treatment of patients by identifying high-risk patterns and initiating in-service programs to prevent future problems.

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