2. GUIDELINES FOR RECORDING
AND REPORTING
Quality documentation and reporting is
necessary to enhance efficient, individualized
client care.
This documentation and reporting have five
important characteristics i.e.-factual, accurate,
complete, current and organized.
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3. 1.FACTUAL:
A record must contain descriptive, objective
information about what a nurse sees, hears,
feels and smells. An objective description is
that which is done by direct observation and
measurement. While recording, do not use any
vague terms like appears, seems or apparently,
because with this terms the nurse gives her/his
own opinion, so patient’s condition is not sure,
it is like assured.
The subjective description includes the client’s
exact words within quotation marks when ever
possible. www.drjayeshpatidar.blogspot.in
4. 2.ACCURATE:
The use of exact measurements establishes
accuracy.
E.g.- intake 360ml of water is more accurate
than client drank an adequate amount of fluid.
Documentation of concise data is clear and
easy to understand. It is essential to avoid the
use of unnecessary words and irrelevant
detail. Use abbreviations carefully to avoid
misinterpretation. While documenting, avoid
spelling mistakes. All documentation should
have date and time and at the end the
caregiver’s signature. Chart only your own
observations and actions.
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5. 3. COMPLETE:
The record which is entered or a written,
report needs to be complete, containing
appropriate and essential information. The
nurse makes written entries in the client’s
medical record, describing nursing care that
is administered and the client’s response.
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6. 4. CURRENT;
The client’s ongoing care should be timely entered. To
increase accuracy and decrease unnecessary
duplication, many health care agencies use records
kept near the client’s bed side, which facilitate
immediate documentation of information as it is
collected from client. E.g.- monitoring of vital signs,
physician’s order, medication card etc.
5.ORGANIZED: The nurse communicates information
in a logical order.
6.CONFIDENTIALITY: all the individual’s record should
be kept confidentially. It should not be disclosed to
any body without permission.
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7. LEGAL GUIDELINES FOR RECORDING
Do not erase, apply correction fluid, or scratch out
errors made while recording. So for any error, just
strike over it and sign the name or initials.
Do not write critical comments about client or care
by other health care professionals. Enter only
objective description of client’s behavior, client
comments should be quoted.
Correct all errors promptly, to avoid error, avoid
rushing to complete charting.
Record all facts and enter only factual data.
Use complete, concise descriptions of care.
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8. Do not leave blank spaces in nurse’s notes, chart
consecutively, like by line: if space is left, draw line
horizontally through it and sign your name at end.
Record all entries legibly and in blank ink and do not
use pencil.
Chart only for your self, never chart for someone
else.
Each entry should be done with time, end with your
signature and title.
For computer documentation keep your password to
yourself. Once logged into the computer, do not
leave the computer screen unattended.
The individual sheet should not be separated from
the complete record.
No stranger is ever permitted to read the records.
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9. The records should be kept in such place, so that
patients and relatives are not accessible to it.
All hospital personal are legally and ethically
obligated to keep in confidence all the information
provided in the records.
All records are filed according to the hospital
custom, so that they can be traced easily. Records
could be arranged- alphabetically, numerically, with
index cards, geographically.
Records are never sent out of the hospital without
doctor’s permission.
Each page of the record should be properly
identified with the name, age, I. P. NO, O.P. NO.
date etc.
Use only standard abbreviations.
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10. MEDICAL RECORD
The medical record provides pertinent data
about the client’s medical history, laboratory
tests and diagnostic study results and the
physician’s proposed treatment plan.
Data in the record are baseline information
about the client’s response to illness and
information about the effect of later treatment
measures.
The medical record is a valuable tool for
checking the consistency of personal
observation.
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11. COMPUTERIZED DOCUMENTATION
Usually the computerized documentation was used in the
hospitals for supplies, equipments, stock medications and
diagnostic testing etc. But now it is wisely used for
documentation.
The transition to computerized documentation presents both
opportunities and challenges to nurse and nurse managers.
The successful implementation of a computerized documentation
systems requires preparation, involvement and commitment of
the entire nursing staff.
In this type of documentation, the nurse quickly enter the specific
assessment data, fill in forms with typical; entry choice.
Computer also help generate nursing care plans and document
all facets of patient care.
A complete computer based patient care record(CPCR) is a
comprehensive system that uses many components of data
collection. The CPCR permits the nurse to have an instrumental
role in development of this form of documentation.
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12. Limitation of computerized documentation:
For documentation nurses requires typical
skills.
Graphic users interfaces (touch pads, mouse
and icons) are not well suited for nursing.
A note book sized computer is good for
nurses to document with ease but it is not
possible in the current systems.
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13. LEGAL RISKS WITH COMPUTERIZED
DOCUMENTATION:
Any person can access a computer station within a
hospital and gain information of any patient.
ACTION TO BE TAKEN FOR SUCH LEGAL PROBLEMS
ARE:
Do not share or give the password to any one except
the person who involved in the same patient care.
Periodical change of personal passwords to prevent
unauthorized persons from tampering with records.
Make a group of staff and they should have authority
to assess all client’s records.
The nurse should know how to correct the charting
errors on a computer, so the incorrect entries must be
corrected record who made the correction and when it
is done. www.drjayeshpatidar.blogspot.in
