records and reports commonly used in nursing field.

3. DEFINITION
Documentation is the written legal record of
all pertinent interactions with the client -
Assessing , diagnosing, planning,
implementing and evaluating.

4. PURPOSES
 COMMUNICATION
oTo promote continuity of care among
departments
oTo get a clear picture of client condition
oEnsure coordination of activities

5.  QUALITY ASSURANCE
o To provide quality of care
o To ensure adequate care
o To make the changes
o To train the staffs
o To take remedies
o To improve the care

6.  REIMBURSEMENT
o To provide cost awareness
o To help for insurance
o To find scarcity of resources

7.  LEGAL ACCOUNTABILITY
o Evidence of court proceeding
o Protection for staffs
o Protection for client

8.  RESEARCH
o To identify the problem
o Identify new ways of approaches
o To improve professional knowledge
o For determine the effectiveness of therapies

9.  DIAGNOSTIC AND THERAPEUTIC ORDERS
o To carryout procedure
o It should signed by medical officer

10.  ASSESSMENT
o Finding client history
o Subjective data
o Objective date

11.  PLANNING
o Finding problems
o Planning the appropriate care

12.  DECISION MAKING
 Identifying needs
 Prevent unnecessary use of care
 Financial management

13.  EDUCATION
o Educational tool for students and health care team
o It help to learn about disease condition and treatments

14.  VITAL STATISTICS
o To provide statistical information for health care
agencies

15. PRINCIPLES
 Date and time
 Correct spelling
 Appropriateness
 Legal evidence
 Accuracy
 Completeness
 Legibility
 Corrections
 Omissions
 Signature
 Confidentiality

16. TYPES OF RECORDS
 Out patient and in patient record
This contain data of the client, diagnosis, history,
investigations, medications, treatment, progress etc
 Nurses recording
large part of the client filled by the nurse
regarding nursing measures like their observations
and care with date & signature
 doctor’s order sheet
prescriptions regarding medicine, investigations
and diet
 Graphic chart of TPR
patient TPR value are mentioned in this graph

17.  Reports of lab examination ( blood, urine scanning
etc)
 Diet sheets ( regarding food to be avoided and
added)
 Consent forms ( before procedure, surgery, &
anesthesia)
 Intake and output chart(intake is fluids taken and
out put based on urine, vomiting amount)
 Registers (statistical reports of cases in hospital,
death, birth registers also maintained)
 Medico legal cases documentation
such as RTA, suicide attempts there is a need
of police intimation

18.  Medication records ( regarding name, dose,
frequency of drugs with signature of nurses)
 Discharge and referral summaries ( regarding
discharge and transferring of patiens)
 Kardexes ( concise method of organizing patient
data it consist of series of cards in a file)
 Flowshe ets ( other vise abbreviated progress
notes give clear picture of patient condition)

19. Reporting
Repots are essential tools of communication
between the members of the health team.

20. Methods of Communication within
the Health Care Team
 Change of shift reports
This is the report given by a primary nurse to the nurse
replacing him/her or by the charge nurse to the nurse
who assumes responsibility for continuing care of the
client. This report can be given in a written form or
orally in a meeting or may be audiotaped

21. Forms of shift report
 Reports among the members of the nursing team
 Reports between the head nurse and her assistants
 Reports between the head nurse and nursing
superintendent
 Reports to the physician
 Reports on mistakes, accidents, and complaints

22.  Telephone / telemedicine reports
with the technological advancement it is
possible to give and take the telephonic order
regarding client. Advantage is can deliver the
message immediately disadvantage is no
permanent record
 Incident reports
it is the document of occurrence of anything
out of the ordinary that result or potential harm
to client, employee or visitors

23. Evaluation reports
Monthly evaluation reports of students are sent to the
principal by head nurse

24. Forms of records (documentation
system)
 Source oriented record
 Problem oriented medical record (POMR)
 Problem, intervention, evaluation (PIE)
 Focus charting
 Charting by exception (CBE)
 Computerized documentation

25. Source oriented record
It is a narrative recording by each member
(source) of the health care team on separate document
from admission to discharge
Problem oriented medical record (POMR
POMR organized around the client’s problem there
are 4 components in POMR
Database (assessments)
Problem list (findings of assessments)
Plan of care (plan for solve the problem)
Progress note

26. Progress note format
SOAP, SOAPIE, SOAPIER
 Subjective data
 Objective data
 Assessment
 Plan
 Intervention
 Evaluation
 Revision

27. PIE RECORD
 The main parts of this system are an integrated plan of
care , assessment flow sheets, and nursing progress
notes
Example
P- imbalanced nutrition
I- encourage small and frequent diet
E- glanced at patient food intake and weight gain

28. FOCUS CHARTING
 Focus charting includes data, action, response
Data- subjective & objective
Action- interventions
Response – evaluation of nursing care

29. Charting by exception
 It is the documentation of only abnormal or significant
finding

30. Computerized documentation
 Computerized clinical record system is being
developed as a way to manage the huge volume of
information required in a health care delivery

31. Issues in Computerized
documentation
 Confidentiality is major concern
 Security
 Training of personnel
 Language used to name the nursing problem
 The individual should have log in and password for
entering the computer record system

32. Advantages
 Legibility of information
 Less time consuming, and accuracy in record keeping
 Provide database for research and quality assurance
 Client information, requests and results are sent and
received quickly
 Standard terminology improves communication
 Easy to transfer

33. Disadvantages
 Client may not have privacy if security measures are
not used
 System failure may cause unavailability of information
temporarily
 System is expensive
 Training is required