Bihar agriculture University sabour Bhagalpur

1. Documentation And
Reporting

2. • Documentation is anything written or printed on
which person rely as record or proof of patient
actions and activities.

3. • Arecord or chart or client record, is a
formal, legal document that provides
evidence of a
client’s care and can be written or computer
based.

4. • Areport is oral, written, or computer-based
communication intended to convey
information to others.

5. • The process of making an entry on a client
record is called recording, charting, or
documenting

6. • Each health care organization has policies
about recording and reporting client data, and
each nurse is accountable for practicing
according to these standards.

8. Purposes:
• The patient record is a valuable source of data for all
members of the health care team.
• Client records are kept for a number of purposes
including:
Communication
Planning client care
Auditing health agencies
Research
Education
Reimbursement
Legal documentation
Health care analysis

9. Communication
• The record serves as the vehicle by which different
health professionals who interact with a client
communicate with each other.
• This prevents fragmentation, repetition, and
delays in client care.

10. Planning Client Care
• Each health professional uses data
from the client’s record to plan care for
that client.
• Nurses use baseline and ongoing data to
evaluate the effectiveness of the using care
plan.
• The physicians plans treatment after
seeing the laboratory reports of patient.

11. Auditing Health Agencies
• An audit is a review of client records for
quality assurance purposes .
• Accrediting agencies such as The Joint
Commission may review client records to
determine if a particular health agency is
meeting its stated standards.

12. 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.

13. Education
• Students in health disciplines often use
client records as educational tools.
• A record can frequently provide a
comprehensive view of the client, the
illness and effective treatment
strategies.

14. Reimbursement
• Documentation also helps a facility
receive reimbursement from the
government.
• For a patient to obtain payment through
Medicare or insurance agencies the
client’s clinical record must contain the
correct diagnosis and reveal that the
appropriate care has been given.

15. Legal Documentation
• The client’s record is a legal document
and is usually admissible in court as
evidence.

16. Health Care Analysis
• Information from records may assist health
care planners to identify agency needs,
such as over utilized and underutilized
hospital services.
• Records can be used to establish the
costs of various services and to identify
those services that cost the agency
money and those that generate revenue.

17. COMMUNICATION WITH IN THE
HEALTH CARE TEAM

18. • 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 50
different professionals, including
physicians, nurses, technicians, and
others

19. • 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

20. All records contain the following
information:
• Patient identification and demographic
data
• Informed consent for treatment and
procedures
• Admission data
• Nursing diagnoses or problems and
nursing or interdisciplinary care plan
• Record of nursing care treatment and
evaluation
• Medical history
• Medical diagnoses

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

22. • 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.

23. • T
eam 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.

24. GUIDELINES / PRINCIPLES
OF RECORDING

25. Guidelines/ principles:
1. Factual
2. Timing
3. legibility
4. Accepted terminology
5. Correct signature
6. Spelling
7. organization

26. 8. Accuracy
9.Sequence
10.Appropriate
11.Complete
12.Concise
13.Legal prudence

27. • Factual
• A factual record contains descriptive, objective
information about what a nurse sees, hears, feels,
and smells.
• Avoid vague terms such as appears, seems, or
apparently because these words suggest that you
are stating an opinion, do not accurately
communicate facts.
• Objective documentation includes
observations of a patient’s behaviors.

28. - For example, instead of
documenting “the patient
seems anxious,” provide
objective signs of anxiety and
document “the patient’s pulse
rate is elevated at 110
beats/min, respiratory rate is
slightly labored at 22
breaths/min, and the patient
reports increased
restlessness.”

29. • The only subjective data included in
the record are what the patient
says.
• When recording subjective data,
document the patient’s exact words
within quotation marks whenever
possible.

30. • Date and Time
• Document the date and time of each
recording.
• This is essential not only for legal reasons but
also for client safety.
• Record the time in the conventional manner
(e.g., 9:00 AM or 3:15 PM) or according to
the 24-hour clock (military clock), which
avoids confusion about whether a time was
AM or PM

31. • Timing
• Follow the agency’s policy about the frequency
of documenting, and adjust the frequency as a
client’s condition indicates.
• for example, a client whose blood pressure is
changing requires more frequent
documentation than a client whose blood
pressure is constant.
• As a rule, documenting should be done as
soon as possible after an assessment or
intervention.
• No recording should be done before
providing nursing care

32. • Legibility
• All entries must be legible and easy to
read to prevent interpretation errors.
• Hand printing or easily
understood handwriting is
usually permissible.

33. • Accepted Terminology
• People in the 21st century are often in a hurry
and use abbreviations when texting .
• Even though using abbreviations is
convenient, medical abbreviations have
been responsible for serious errors and
deaths .
• Use only the standard and recognized
abbreviations.
• Ambiguity occurs when an abbreviation can
stand for more than one term leading to
misinterpretation.

34. - For example CP stand for
chest pain, cerebral palsy,
cleft palate, creatine
phosphate, and
chickenpox

35. • Correct Spelling
• Use correct spelling while documenting.
• Correct spelling is essential for
accuracy in recording.Avoid spelling
mistakes
• If unsure how to spell a word, look it up
in a dictionary or other resource .
• Two obsolutelydifferent medications may have
similar spellings; for example, Fosamax and
Flomax

36. • Signature
• Each recording on the nursing notes is
signed by the nurse making it.
• The signature includes the name and title;
for example, “M.S. REDDY, RN”
• With computerized charting, each nurse
has his or her own password, which
allows the documentation to be
identified.

37. • Accuracy
• The client’s name and identifying
information should be stamped or written
on each page of the clinical record.
• Before making any entry, check that it is
the correct chart.
• Do not identify charts by room number
only; check the client’s name.
• Special care is needed when caring for
clients with the same name.

38. • When a recording mistake is made, draw a
single line through it to identify it as
erroneous with your initials or name above
or near the line (depending on agency
policy).
• Do not erase, blot out, or use correction
fluid.
• The original entry must remain visible.
• When using computerized charting, the
nurse needs to be aware of the agency’s
policy and process for correcting
documentation mistakes.

39. • Write on every line but never between
lines. If a blank appears in a notation,
draw a line through the blank space so
that no additional information can be
recorded at any other time or by any other
person, and sign the notation

40. • Sequence
• Document events in the order in which
they occur;
• for example, record assessments, then
the nursing interventions, and then the
client’s responses.

41. • Appropriateness
• Record only information that pertains to
the client’s health problems and care.
• Any other personal information that the
client conveys is inappropriate for the
record.
• Recording irrelevant information may be
considered an invasion of the client’s
privacy .

42. • 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.
• Nurses’ notes need to reflect the nursing
process.
• Record all assessments, dependent and
independent nursing interventions, client
problems, client comments and responses to
interventions and tests, progress toward goals,
and communication with other members of the
health team.

43. • Conciseness
• Recordings need to be brief as well as
complete to save time in
communication.
• Repeated usage of the client’s name and
the word client are omitted.

44. • Legal Prudence
• Accurate, complete documentation should
give legal protection to the nurse, the client’s
other caregivers, the health care facility, and
the client.
• Admissible in court as a legal document, the
clinical record provides proof of the quality of
care given to a client.

45. - For the best legal protection,
the nurse should not only
adhere to professional
standards of nursing care but
also follow agency policy and
procedures for intervention
and documentation in all
situations—especially high-
risk situations.

46. Omission
- Blank spaces are not to be left
on the chart
- Avoid writing outside of the
charting format
- A horizontal lines is drawn
through any empty space to
the right margin to prevent
later entries being made in
front of the signature

47. Confidentiality
- All clients records are
confidential files that requires
written permission of the client
to be copied.
- Information within the chart is
often of a personal matter as
well as legal evidence of the
care provided and should be
available to the necessary
health team members only.

48. Contents of documentation
- Health care agencies vary in there specific
requirement about what need to charted, yet there
should be a systematic method to be followed, in the
documentation of the client care
- All significant client care should be documentated
either in narrative (progress) notes or on flow sheets

49. Types of enteries
- Admission notes
- Change of shift note
- Assignment notes
- Interval or progress notes
- Transfer and discharge notes
client teaching notes
- Descriptions of observations
- Symptoms and complaints
- Dressing tubes or attached
devices

50. - Medications and treatment
- Observation of psychosocial
status
- Activity of daily living
- Valuables
- Spiritual care
- safety concern
- documentation

51. Admission notes (admit notes)
- It is the nurses first notes acknowledging the arrival
of a new client. Following the admit note, a
narrative entry, nothing the complete assessment
is made. This is followed by a description of the
client current status at appropriate intervals, clients
orientation to the faculty should be made

52. Change of shift notes
- During each shift,
documentation of the clients
assessment made is done

53. Interval or progress
notes
- After the complete assessment, interval or
progression daily notes are made. This
include change in the clients condition,
test or investigation, any state or prn
medication, and procedure, treatment,
new orders, ambulation, period of rest and
client symptom
- Usually notes are made at an interval of
2-4 hrs

54. Transfer and discharge notes
- When the client is transferred to another faculty either
temporary or permanent, a transfer notes are written.
This notes may include reason for transfer, method of
transportation, person giving and receiving the report,
notification of the physician or family member and the
condition of the client, including vital signs and
treatment in progress
- A discharge notes is a nursing notes that reflects the
circumstances around the release of a client from the
faculty

55. Client teaching notes
- Instruction given to a client need careful
study. All teaching occur must be noted
including reinforcement of the
information already taught. Is also state
the clients response to teaching

56. Description of observation
- Nurses notes should not be recorded
objectively. Opinions should not be recorded.
Subjective data present by the client are
included in the nurses notes and should be
clearly labeled as such

57. Symptoms and complaints
- Any symptom or complaints
by client should be
documented in details. This
can include subjective or
objective data and must be
specific in terms of location,
duration, intensity, amount,
size and frequency.

58. Dressing tubes or attached
devices
- Observation of tube must be documented in the
initial entry of each shift and at least every 2 hr
thereafter, the documentation of dressing should
include, location of dressing, amount as well as
description of any drainage observed, condition of
the skin/wound also must be must be described

59. Medication and treatment
- Usually there will be a medication administration
record. When all the medication are administrated,
charting is done. If a medication is not given, the
reason for that should be documented and it is
better to inform the physician concerned.

60. Observation of psychosocial
status
- Document the client
sensorium in relation to level
of consciousness and
orientation to time, place and
person.
- Clints leave against medical
advice (L.A.M.A.) must be
documented clearly with the
reason for the L.A.M.A.

61. Activity of daily living
- These are documented
primirly on flow sheets and
must be recorded by the
person administering care.
The documentation includes
types of ADL, types of
assistance and the number of
health worker needed to move
a client

62. valuable
- Depending on the policy of the health care
institution, valuables are either kept in
health care setting after proper
identification, description of each specific
item, signature by the client and two health
care professional or it may sent home with
a responsible family member and
document the name of the person who took
the valuable and his/her relationship either
the client

63. Safety concern
- Safety measures taken for the
client must be documented in
detail

64. Documentation
- Documentation for special
groups such as older adult,
children, and culturally diverse
client

65. Documentation
format
- Narrative charting
- Problem focused charting
a) APIE charting
b) SOAP charting
c) Focused charting
d) Exception
e) FACT system
f) Core
g) Outcome documentation
h) Case management model

66. Narrative charting
- It is a free style method of
documentation. A charting
that provides information in
the form of statement that
describe events surrounding
client care. It is often relatively
unstructured and so provide
flexibility in determining how
information is recorded or the
format may be structured and
problem focused.

67. Problem focused
charting

68. APIE charting
- A - Assessment
- P - Problem identification
- I - Intervention
- E- Evaluation
- The process begin with an admission assessment
that is usually completed on a separate form and
the initiation of a problem list (which may be in the
form of a nursing diagnosis or a problem statement)
that is based on the initial assessment.

69. - Documentation of client care is focused on
intervention and evaluation related to problem list.

70. Advantage
- it promote continuity of care.
- It save time because there is no separate plan of
care.

71. Disadvantage
- There is no formal care plan and so nurses need to
read all the nursing notes to determine problem and
plant intervention before initiating care

72. SOAP charting
- S – subjective data
- O – objective data
- A – assessment
- P – plan
- This is use to record progress notes with problem
focused charting. The progress notes include
narrative notes, as well as flow sheet and they are
used by all member of health team

73. Advantage
- A uniform problem list used by all personnel and
easy reference to data related to specific problem

74. Disadvantage
- Lack of flexibility as all documentation is directed
toward specific problem

75. Focus charting
- It is a method of charting, that addresses client
problem or needs and includes a column that
summaries the focus of entry.
- Instead of problem list or a list of medical or nursing
diagnosis, a focused column is used that
incorporate many aspects of a client and client care

76. Advantage
- The holistic emphasizes on the client and the client
priorities, and the ease of charting and flexibility

77. Disadvantage
- The possibilities of inconsistency in the labeling of
the problems.

78. Charting by
exception
- It is shorthand documentation method that makes
use of well defined standard of practice. Only
significant findings or exception to this standards
are documented in narrative notes

79. Advantages
- Decreased charting time
- Greater emphasizes on significant data
- Easy retrial of significant data
- Timing bed side charting
- Standardize assessment
- Greater interdisciplinary communication
- Better tracing of important client response
- Lower cost

80. Drawbacks
- It is more difficult to identify the omission in care
- Often detail of care are limited
- More difficult to follow nursing process using this
format
- Charting by exception may be misleading when
defending care from a legal point of view

81. FACT system
- F – flow sheet that are individualize
- A – assessment sheet that are standardized with
baseline parameter
- C – concise integrated progress notes and flow
sheets that are used to demented the client
condition and response
- T – timely entries that are recorded after care is
given

82. Core
- The core documentation system focuses on the
nursing process. It consist of a database, plan of
care, flow sheet, progress note and discharge
summary.

83. Outcome
documentation
- This system focuses on the clients behavior. It
gives the clients condition in relation to
predetermine outcome

84. Case management
model
- The emphasizes quality, cost effective care deliver
within an established length of stay(LOS) this
system uses the multidisciplinary approach to
planning and documenting care using critical
pathways.

85. Care of records
- The records are kept under custody of the nurse in
each ward or department
- No individual sheet is separated from the complete
record
- Records are kept in a place , not assessable to the
clients or visitors
- No strangers are ever permitted to read the records
- All hospital personnel are legally and ethically
obligated to keep in confidence all the information
provided in the records

86. - All records are to be handled carefully. Careless
handling can destroy the records
- All records are filled according to the hospital
custom so that they can be traced easily
- All records are identified with the bio-data of the
clients such as name, age, ward, bed no, diagnosis
etc
- Records are never sent out of the hospital without
the doctors permission

87. Types of records
- Out-patient and in-patient records
- Nurses recording
- Doctors record sheet
- Graphic chart of TPR
- Reports of lab. Examination
- Diet sheet
- Consent form for operation and anaesthesia
- Intake output chart
- registers

88. - Medicolegal cases-
documentation
- Medication records
- Daily nursing care record
- Progress notes
- Nursing discharge/referral
summaries
- Homecare documentation
- Flow sheet

89. Reports
- Reports are the effective
means of communication
among the member of health
team . In a report an account
of something that has been
seen, heard, done or
considered is given.

90. Objectives
- Report are essential tools of communication between
the member of health team. By using good report, the
information about the change that are taking place in
the client general health, the result of treatment which
are unusual or significant are exchanged among the
member throughout the day
- Good report will indicate the efficiency of the health
team in carrying out their assignments
- Good report will avoid duplication of work

91. - Good report will tell us why a particular procedure is
done or not done
- Good report will help the relieving personnel's to plan
the future care of clients without wasting time
unnecessarily
- Client receive better care when the reports are through
and give all pertinent data.
- Good report will tell us about the problems relating to
supplies and equipment

92. Method of communication of
reports
- Change of shift notes
a) Report between the head nurse and her assistance
b) Report between the head nurse and nursing
superintendent
c) Report to the physician
d) Report on mistakes, accident and complaints
e) evaluation reports

93. - Telephone/telemedicine
report
- Incident report
- Evaluation report s

94. Computers in
documentation
- Computer based records are used in any health
care setting to facilitate delivery of client care and
support the data analysis necessary for strategic
planning. Compute based record contain identical
information that is found in traditional records, but
they eliminate repetitive entries and allow more
freedom of assess the data based

95. Issues in computer
based records
- Confidentiality is a major concern
- Security
- Training of personnel
- Language used to name the nursing problem
- Constant change in medical and nursing informatics
- The individual should have a log in and pasword for
entering the computer record system

96. Advantage
- Legibility of information
- Increased time efficiency, consistency and accuracy
in record keeping
- Provide data base for research and quality
assurance
- It links various resources of client information
- Client information requests and results are result are
sent and received quickly
- Standard terminology improves communication

97. - This system incorporates and reinforces standards
of care.
- Computer records can facilitate a focus on clients
outcomes
- It is possible to transfer information entered into the
system to other areas
- Bedside charting system referred to as point of care
(POC) system gives more accurate and complete
records

98. - Bedside terminals can
synthesize information from
monitoring equipment

99. Disadvantages
- Clients may not have privacy if security measures
are not used
- System failure can cause unavailability of
information temporarily
- System is expensive
- Extended training period may be required whatever
an updated system is installed