Effective recording and reporting techniques for nurses

EFFECTIVE RECORDING AND
REPORTING TECHNIQUES FOR
NURSES
Mathew Varghese V
BSN,FHNP,CPEPC,MSN(Pursuing)
Nursing Officer
AIIMS
New Delhi
19/06/2019
1
mathewvmaths@yahoo.co.in

INTRODUCTION
 Reporting and recording are the major
communication techniques used by health care
providers
 Records are a practical and indispensable aid to
doctor, nurse and paramedical personnel in
giving the best possible service to their clients.
 Recorded facts have value and scientific
accuracy for more than mere impression of
memory and there are guidelines for better
administration of health services.
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2

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3

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4

IN OUR HOSPITAL
7.97
7.33
5.76
7.21
6.55
5.36
Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19
Percentage of Incompleted Records
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5

COMMON ERRORS OF DOCUMENTATION
Sign missing Overwriting
Incompleted
Nurse’s
records
Small letter
use
Medication
chart stop
note missing
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SIGN MISSING
91
77
96
123
117
106
0
20
40
60
80
100
120
140
1-Dec 1-Jan 1-Feb 1-Mar 1-Apr 1-May
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INCOMPLETED NURSE’S RECORDS
0
10
20
30
40
50
60
58
55
52
49
31
19
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OVER WRITING
8
4
5
3
2
3
0
1
2
3
4
5
6
7
8
9
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9

MEDICATION CHART STOP NOTE MISSING
0
2
4
6
8
Dec-18 Jan-19
Feb-19
Mar-19
Apr-19
May-19
3 3
7
1
3
4
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SMALL LETTER USE
0
5
10
15
Dec-18 Jan-19
Feb-19
Mar-19
Apr-19
May-19
15
8
2 2 3
0
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MR SIGN MISSING
1786
1976
163
27
0
500
1000
1500
2000
2500
1-Apr 1-May
Total discharge
MR Sign Missing
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DEFINITION – RECORD
 A record is a permanent written communication
that documents information relevant to a
client’s health care management
-Potter and Perry
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PURPOSES OF DOCUMENTATION
COMMUNICATION
FINANCIAL BILLING
EDUCATION
ASSESSMENT & MONITORING
RESEARCH
AUDITING AND QUALITY ASSURANCE
LEGAL ASPECT
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PRINCIPLES OF RECORD WRITING
 Nurses should develop their own method of
expression and form in record writing.
 Write clearly, appropriately and adequately.
 Record should contains facts based on
observation, conversation and action.
 Select relevant facts and the recording should
be neat, complete and uniform
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PRINCIPLES OF RECORD WRITING
 Record is a valuable legal document and so it
should be handled carefully.
 Records should be written immediately after the
procedure
 Records are confidential documents.
 It should be Accurately dated, timed and signed
 It should not include abbreviations, jargon,
meaningless phrases
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CHARACTERISTICS OF A GOOD
DOCUMENTATION
Accuracy
Consciousness
Thoroughness
Up to date
Organization
Confidentiality
Objectivity
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HOW TO IMPROVE DOCUMENTATION?
 Use of Common Vocabulary
 Use common terms and words which improves
communication and lessens the chance of
misunderstanding between members of the health
team.
 Patient has prostration
 Patient has consternation
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EFFECTIVE DOCUMENTATION TECHNIQUES
 Legibility
 Print if necessary.
 Do not erase or obliterate writing.
 State the reason for the error.
 Sign and date the correction.
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 Use Standard Abbreviations and Symbols
 Always refer to the facility’s approved listing.
 Avoid abbreviations that can be misunderstood.
 Pt,GC
 BD,TDS,HS
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 Organization
 Start every entry with the date and time.
 Chart in chronological order.
 Chart medications immediately after administration.
 Sign your name after each entry.
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 Accuracy & Completeness
 Use descriptive terms to chart exactly what was
observed or done.
 Use correct spelling and grammar.
 Write complete sentences.
Case S/B duty Doctor.
Given analgesics
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 Confidentiality
 The nurse is responsible for protecting the privacy
and confidentiality of client interactions,
assessments, and care.c
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 Factual
 A factual record contains descriptive, objective
information about what a nurse sees, hears, feels &
smells.
 An objective description is the result of direct
observation & measurement.
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 Timing
 Timely entries are essential in a patient’s ongoing
care.
 Document immediately after the procedure
 Delays in documentation leads to unsafe patient
care.
 Health organizations use military time to avoid
misinterpretation of AM & PM
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FOLLOWING ACTIVITIES SHOULD ENTER
TIMELY
 Vital signs
 Pain assessment
 Administration of medication & treatment,
 Preparation for diagnostic test or surgery,
 Change in patient’s status & who notified
 Admission, transfer, discharge or death of the
patient
 Patient’s response to treatment
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SOAPIER
FORMAT OF DOCUMENTATION
SUBJECTIVE
What patient tells you?
OBJECTIVE
What you observe or see?
ASSESSMENT
What you think is going on based on your data?
PLAN
What you are going to do?
INTERVENTION
Specific interventions implemented
EVALUATION
Patient response to interventions
REVISION
Changes in treatment
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REPORT
 A report is a summary of activities or observations
seen, performed or heard.
-Potter and Perry
 Reports can be compiled daily, weekly, monthly,
quarterly and annually.
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PURPOSES OF REPORT
 Report is an essential tool to communication
 To show the kind and amount of services
rendered over a specific period.
 As an aid in planning.
 To interpret the services to the public and to the
other interested agencies.
 It helps in efficient management of the ward
 Complete reports give a sense of security which
comes from knowing all factors in the situation.
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TYPES OF REPORTS
 Oral reports :
 Oral reports are given when the information is
for immediate use and not for permanency. E.g.
it is made by the nurse who is assigned to
patient care, to another nurse who is planning
to relieve her.
 Written reports :
 Reports are to be written when the information
to be used by several personnel, which is more
or less of permanent value, e.g. day and night
reports, census, incidental report , Birth and
death report
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EFFECTIVE REPORTING TECHNIQUES
 Before anything can be written clearly, it must
be clear in one’s own mind.
 Reports, lacking facts, may be biased or
worthless.
 Conciseness, accuracy and completeness are
essential to good reports.
 Use goods sentences and paragraphs
 Observe margins
 Use terminology in keeping with the nature of
reports:
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EFFECTIVE REPORTING TECHNIQUES
 Don’t forget punctuation
 Be neat
 Write report in a conversational manner.
 Date reports
 If report is typed by someone else, check it
before signing it.
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FACT CRITERIA FOR REPORTING
 F = Factual
 A = Accurate
 C = Complete
 T = Timely
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FACTUAL
 Only information you see, hear, or otherwise collect
through your senses
 Describe, don’t label
 State facts, not value judgments such as “No
change” “Ate well”
 Be specific
 Use neutral language
 Avoid bias
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FACTUAL
When you make an error:
 State exactly what you did or failed to do
 State that you notified the patient’s provider, and
the provider’s response
 Do not state “by mistake” or explain how the error
occurred
 Report this occurrence on the incident report (or
form your organization uses for error
documentation) and to relevant staff members
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ACCURATE
 Be precise
 Quantify whenever possible
 Be sure to make clear who gave the care
 When countersigning with a student or another
nurse, review the content of the documentation and
document your own follow-up assessment,
interventions if any, and the patient’s response
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COMPLETENESS
Complete Include:
 Condition change
 Patient responses, especially unusual, undesired or
ineffective response
 Communication with patient and family
 Entries in all spaces on all relevant assessment forms
 Use N/A or other designation for items that do not apply
to your patient
 DO NOT LEAVE BLANKS
 Blanks are hazardous because they permit entries
above your signature
 Others may make entries in such blanks by mistake or
to purposely falsify records
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TIMELY
 When a medical record is examined in a malpractice or
negligence case, date and time are critical in
establishing a timely response to a patient need.
 Resist the temptation to leave documentation until the
end of the shift
 You may forget key pieces of information when rushing
 Charting as your shift progresses will help keep your
documentation accurate
 Other professionals who access the record need to have
up-to-date data to guide care
 NEVER document in advance o This practice is illegal
falsification of the record
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VERBAL ORDER GUIDELINES
 Follow organizational policy concerning
documentation of orders and diagnostic test results
received orally in person or via telephone.
 Requires read-back of verbal orders.
 Receive the verbal or telephone order directly and
not through a third party
 Write down the order exactly as the provider gives it
and the date and time
 Read back the order to the provider and assure
that you have the same understanding
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VERBAL ORDER GUIDELINES
 State, “five-zero “rather than saying “fifty” which
could be misunderstood as “fifteen”
 If there is any question, spell, or ask the prescriber
to spell drug names
 When spelling, assure that sound-alike letters are
correctly interpreted, state “B as in ball’”
 Obtain confirmation from the provider that the
order is correct as you have read it back
 Record the order in the patient’s record as soon as
reasonably possible.
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TELEPHONIC ETIQUETTE
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THANK YOU
19/06/2019mathewvmaths@yahoo.co.in45

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