This document discusses documentation, recording, and reporting in healthcare. It defines documentation as written records of patient care and activities. Recording involves making entries in a patient's chart. Reports convey information orally or in writing. The purposes of reports and records include communication, planning care, legal documentation, research, education, auditing, reimbursement, and analysis. Key elements of legal and proper documentation include date, time, legibility, permanence, terminology, spelling, signature, accuracy, sequence, appropriateness, completeness, conciseness, and being factual. Guidelines for reporting emphasize being factual, accurate, complete, focused on current issues, and well-organized. Common types of reports include shift reports, transfer reports, telephone

1. PREPARED BY
IDUNA SOPHIA DCOUTO
ASSOCIATE PROFESSOR
NHCON
DOCUMENTATION AND
RECORDING

2. DOCUMENTATION
 Documentation is anything written or printed
on which you rely as record or proof of patient
actions and activities.- Potter and Perry
 The process of making and entry on a client
record is called recording, charting or
documenting. - Kozier

3. REPORTING
 A report is oral, written or computer
based communication intended to
convey information to others.
RECORD
 It is also called a chart or client record,
is a formal, legal document that provides
evidence of a clients care and can be
written or computer based.

4. PURPOSES OF REPORTS AND
RECORD
 1. Communication
 2. Planning client care
 3. Legal documentation
 4. Research
 5. Education
 6. Auditing Health Agencies
 7.Reimbursement
 8. Health Care Analysis

5. CONFIDENTIALITY

6. TYPES OF CLIENT
RECORDS/COMMON RECORD
KEEPING FORMS
MEDICAL RECORDS
 1. Patient identification and demographic data
 2. Present complaints
 3.Informed consent for treatment and procedure
 4. Admission nursing history
 5.Family history
 6. Physical examination findings
 7. Medical history
 8. Tentative diagnosis
 9. Medical diagnosis
 10.Theraputic orders

7. Con’t
 11. Treatment given
 12. Medical progress notes
 13. Supportive care given
 14. Reports of diagnostic studies
 15. Final diagnosis
 16. Patient education
 17. Summary of operative pocedures
 18. Discharge plan and summary
 19. Any specific special instructions

8. COMMON NURSING RECORDS/
FORMATS FOR NURSING
DOCUMENTATION
 1. Nursing assessment
 2. Nursing care plans
 3. Kardexes

9. CON’T
 4. Flow sheets
 5. Graphic records
 6. Fluid balance record
 7. Medication administration form
 8.Skin assessment record
 9. Progress notes

10. METHODS /SYSTEMS OF
DOCUMENTATION/RECORDING
 1. SOURCE – ORIENTED RECORD
 2. PROBLEM – ORIENTED MEDICAL RECORD
(POMR)/PROBLEM ORIENTED RECORD (POR)
o 1.Database
o 2.Problem list
o 3. Plan of care
o 4. Progress notes
3. PIE
4. FOCUS CHARTING

11. CON’T
 5. CHARTING BY EXCEPTION (CBE)
 1. Flow sheets
 2. Standards of nursing care
 3. Bedside access to chart forms
6. COMPUTERIZED DOCUMENTATION/ ELECTRONIC
MEDICAL RECORDS (EMR)
7. CASE MANAGEMENT
8. PERSONAL HEALTH RECORDS (PHRs)

12. LEGAL GUIDELINES FOR
DOCUMENTATION
 Date and Time
 Timing
 Legibility
 Permanence
 Accepted terminology
 Correct spelling
 Signature
 Accuracy
 Sequence
 Appropriateness
 Completeness
 Conciseness
 Legal Prudence
 Factual

13. REPORTING
 Reports are oral written or audio taped exchange
of information between caregivers
Purposes of writing reports
1. To identify the quality of service
2. To show the progress in reaching goal
3. To study health conditions
4. To interpret the services to the public and to
other agencies

14. CRITERIA OF A GOOD REPORT
 Made promptly
 To be clear, concise and complete
 All identified data to be included
 Easily understood
 Important points to be emphasized

15. GUIDELINES FOR REPORTING
Factual
Accurate
Complete
Current issue
Organisation

16. TYPES OF REPORT
1. Change of shift report/hand off
communication
2. Transfer reports
3. Telephone reports
4. Incident report/ accident report
5. Intra division reports
6. Inter departmental reports
7. Care Plan Conference
8. Nursing rounds