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Guidelines for recording and reporting


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Guidelines for recording and reporting

  2. 2. GUIDELINES FOR RECORDINGAND REPORTINGQuality documentation and reporting isnecessary to enhance efficient, individualizedclient care.This documentation and reporting have fiveimportant characteristics i.e.-factual, accurate,complete, current and
  3. 3. 1.FACTUAL:A record must contain descriptive, objectiveinformation about what a nurse sees, hears,feels and smells. An objective description isthat which is done by direct observation andmeasurement. While recording, do not use anyvague terms like appears, seems or apparently,because with this terms the nurse gives her/hisown opinion, so patient’s condition is not sure,it is like assured.The subjective description includes the client’sexact words within quotation marks when everpossible.
  4. 4. 2.ACCURATE:The use of exact measurements establishesaccuracy.E.g.- intake 360ml of water is more accuratethan client drank an adequate amount of fluid.Documentation of concise data is clear andeasy to understand. It is essential to avoid theuse of unnecessary words and irrelevantdetail. Use abbreviations carefully to avoidmisinterpretation. While documenting, avoidspelling mistakes. All documentation shouldhave date and time and at the end thecaregiver’s signature. Chart only your ownobservations and
  5. 5. 3. COMPLETE:The record which is entered or a written,report needs to be complete, containingappropriate and essential information. Thenurse makes written entries in the client’smedical record, describing nursing care thatis administered and the client’s
  6. 6. 4. CURRENT;The client’s ongoing care should be timely entered. Toincrease accuracy and decrease unnecessaryduplication, many health care agencies use recordskept near the client’s bed side, which facilitateimmediate documentation of information as it iscollected from client. E.g.- monitoring of vital signs,physician’s order, medication card etc.5.ORGANIZED: The nurse communicates informationin a logical order.6.CONFIDENTIALITY: all the individual’s record shouldbe kept confidentially. It should not be disclosed toany body without
  7. 7. LEGAL GUIDELINES FOR RECORDING Do not erase, apply correction fluid, or scratch outerrors made while recording. So for any error, juststrike over it and sign the name or initials. Do not write critical comments about client or careby other health care professionals. Enter onlyobjective description of client’s behavior, clientcomments should be quoted. Correct all errors promptly, to avoid error, avoidrushing to complete charting. Record all facts and enter only factual data. Use complete, concise descriptions of
  8. 8.  Do not leave blank spaces in nurse’s notes, chartconsecutively, like by line: if space is left, draw linehorizontally through it and sign your name at end. Record all entries legibly and in blank ink and do notuse pencil. Chart only for your self, never chart for someoneelse. Each entry should be done with time, end with yoursignature and title. For computer documentation keep your password toyourself. Once logged into the computer, do notleave the computer screen unattended. The individual sheet should not be separated fromthe complete record. No stranger is ever permitted to read the
  9. 9.  The records should be kept in such place, so thatpatients and relatives are not accessible to it. All hospital personal are legally and ethicallyobligated to keep in confidence all the informationprovided in the records. All records are filed according to the hospitalcustom, so that they can be traced easily. Recordscould be arranged- alphabetically, numerically, withindex cards, geographically. Records are never sent out of the hospital withoutdoctor’s permission. Each page of the record should be properlyidentified with the name, age, I. P. NO, O.P. etc. Use only standard
  10. 10. MEDICAL RECORDThe medical record provides pertinent dataabout the client’s medical history, laboratorytests and diagnostic study results and thephysician’s proposed treatment plan.Data in the record are baseline informationabout the client’s response to illness andinformation about the effect of later treatmentmeasures.The medical record is a valuable tool forchecking the consistency of
  11. 11. COMPUTERIZED DOCUMENTATIONUsually the computerized documentation was used in thehospitals for supplies, equipments, stock medications anddiagnostic testing etc. But now it is wisely used fordocumentation.The transition to computerized documentation presents bothopportunities and challenges to nurse and nurse managers.The successful implementation of a computerized documentationsystems requires preparation, involvement and commitment ofthe entire nursing staff.In this type of documentation, the nurse quickly enter the specificassessment data, fill in forms with typical; entry choice.Computer also help generate nursing care plans and documentall facets of patient care.A complete computer based patient care record(CPCR) is acomprehensive system that uses many components of datacollection. The CPCR permits the nurse to have an instrumentalrole in development of this form of
  12. 12. Limitation of computerized documentation: For documentation nurses requires typicalskills. Graphic users interfaces (touch pads, mouseand icons) are not well suited for nursing. A note book sized computer is good fornurses to document with ease but it is notpossible in the current
  13. 13. LEGAL RISKS WITH COMPUTERIZEDDOCUMENTATION: Any person can access a computer station within ahospital and gain information of any patient.ACTION TO BE TAKEN FOR SUCH LEGAL PROBLEMSARE: Do not share or give the password to any one exceptthe person who involved in the same patient care. Periodical change of personal passwords to preventunauthorized persons from tampering with records. Make a group of staff and they should have authorityto assess all client’s records. The nurse should know how to correct the chartingerrors on a computer, so the incorrect entries must becorrected record who made the correction and when itis done.
  14. 14. Thank