documentation and reporting For nursing and other health care students

1. Concepts of Nursing-NUR 123
Documentation and Reporting
NUR 212-NUR211
Legal Aspects of Nursing

2. Concepts of Nursing-NUR 123
Documentation
 Reporting and recording are the major
communication techniques used by
health care providers.

3. Concepts of Nursing-NUR 123
Documentation as
Communication
 Documentation is defined as written
evidence of:
• The interactions between and among health
professionals, clients, their families, and
health care organizations.
• The administration of tests, procedures,
treatments, and client education.
• The results or client’s response to these
diagnostic tests and interventions.

4. Concepts of Nursing-NUR 123
Purposes of Health Care
Documentation
 Professional Responsibility and Accountability
 Communication
 Education
 Research
 Legal and Practice Standards

5. Concepts of Nursing-NUR 123
Legal and Practice Standards
 Informed consent means that the client
understands the reasons and risks of the
proposed intervention.
 Witnessing confirms that the person who
signs the consent is competent.

6. Concepts of Nursing-NUR 123
Elements of Effective
Documentation
 Use of Common Vocabulary
 Legibility
 Abbreviations and Symbols
 Organization
 Accuracy
 Documenting a Medication Error
 Confidentiality

7. Concepts of Nursing-NUR 123
Elements of Effective
Documentation
 Use of Common Vocabulary
• Improves communication and lessens the
chance of misunderstanding between
members of the health team.

8. Elements of Effective
Documentation
 Legibility
• Print if necessary.
• Do not erase or obliterate writing.
• State the reason for the error.
• Sign and date the correction.

9. Concepts of Nursing-NUR 123
Elements of Effective
Documentation
Correcting a documentation error

10. Concepts of Nursing-NUR 123
Elements of Effective
Documentation
 Abbreviations and Symbols
• Always refer to the facility’s approved listing.
• Avoid abbreviations that can be
misunderstood.

11. Elements of Effective
Documentation
 Organization
• Start every entry with the date and time.
• Chart in chronological order.
• Chart medications immediately after
administration.
• Sign your name after each entry.

12. Elements of Effective
Documentation
 Accuracy
• Use descriptive terms to chart exactly what
was observed or done.
• Use correct spelling and grammar.
• Write complete sentences.

13. Elements of Effective
Documentation
 Documenting a Medication Error
• Document in the nurses’ progress notes:
- Name and dosage of the medication
- Name of the practitioner who was notified of the error
- Time of the notification
- Nursing interventions or medical treatment
- Client’s response to treatment

14. Elements of Effective
Documentation
 Confidentiality
• The nurse is responsible for protecting the
privacy and confidentiality of client
interactions, assessments, and care.

15. Methods of Documentation
 Narrative Charting
 Source-Oriented Charting
 Problem-Oriented Charting
 PIE Charting
 Focus Charting
 Charting by Exception (CBE)
 Computerized Documentation
 Case Management with Critical Paths

16. Methods of Documentation
 Narrative Charting
• Describes the client’s status, interventions
and treatments; response to treatments is in
story format.
• Narrative charting is now being replaced by
other formats.

17. Methods of Documentation
 Source-Oriented Charting
• Narrative recording by each member (source)
of the health care team on separate records.
• For example the admission department has an
admission sheet, nurses use the nurses’
notes, physicians have a physician notes,
etc….

18. Concepts of Nursing-NUR 123
Methods of Documentation
 Problem-Oriented Charting
• Uses a structured, logical format called S.O.A.P.
- S: subjective data
- O: objective data
- A: assessment (conclusion stated in a form of nursing
diagnoses or client problems)
- P: plan
 Uses flow sheets to record routine care.
 SOAP entries are usually made at least every 24 hours
on any unresolved problem.

19. Concepts of Nursing-NUR 123
Methods of Documentation
 PIE Charting
• P: Problem statement
• I: Intervention
• E: Evaluation
Example:
• P: Patient reports pain at surgical incision as 7/10 on 0 to 10 scale
• I : Given morphine 1mg IV at 2335.
• E : Patient reports pain as 1/10 at 2355.

20. Concepts of Nursing-NUR 123
Methods of Documentation
 Focus Charting
• A method of identifying and organizing the narrative
documentation of all client concerns.
• Uses a columnar format within the progress notes to
distinguish the entry from other recordings in the
narrative notes (Date & Time, Focus, Progress note)
• The progress notes are organized into: Data (D),
Action (A), Response (R).

21. Example of focus charting
Date & Time Focus: Progress notes:
05.Jan.2011 Acute pain related to surgical incision D: Patient reports pain as 7/10 on 0 to 10 scale.
A: Given morphine 1mg IV at 2335.
R: Patient reports pain as 1/10 at 2355.
Concepts of Nursing-NUR 123

22. Concepts of Nursing-NUR 123
Methods of Documentation
 Charting by Exception (CBE)
• The nurse documents only deviations from
pre-established norms (document only
abnormal or significant findings).
• Avoids lengthy, repetitive notes.

23. Concepts of Nursing-NUR 123
Methods of Documentation
 Computerized Documentation
• Increases the quality of documentation and
save time.
• Increases legibility and accuracy.
• Facilitates statistical analysis of data.

24. Concepts of Nursing-NUR 123
Methods of Documentation
 Case Management Process
• A methodology for organizing client care
through an illness, using a critical pathway.
• A critical pathway is a multidisciplinary plan
or tool that specifies assessments,
interventions, treatments and outcomes of
health related problems a cross a time line.

25. Concepts of Nursing-NUR 123
Forms for Recording Data
 Kardex
 Flow Sheets
 Nurses’ Progress Notes
 Discharge Summary

26. Concepts of Nursing-NUR 123
Forms for Recording Data
 The Kardex is used as a reference throughout
the shift and during change-of-shift reports.
• Client data (e.g name, age, admission date, allergy)
• Medical diagnoses and nursing diagnoses
• Medical orders, list of medications
• Activities, diagnostic tests, or specific data on the pt.

27. Concepts of Nursing-NUR 123
Forms for Recording Data
Flow Sheets
 The information on flow sheets can be formatted to
meet the specific needs of the client.
(e.g.: graphic sheets for vital signs, intake & output
record, MAR, skin assessment record).
Nurses’ Progress Notes
 Used to document the client’s condition, problems
and complaints, interventions, responses,
achievement of outcomes.

28. Concepts of Nursing-NUR 123
Forms for Recording Data
 Discharge Summary
• Client’s status at admission and discharge.
• Brief summary of client’s care.
• Interventions and education outcomes.
• Resolved problems and continuing need.
• Referrals.
• Client instructions.

29. Concepts of Nursing-NUR 123
Reporting
 Verbal communication of data regarding the
client’s health status, needs, treatments,
outcomes, and responses
 Reporting is based on the nursing process.

30. Concepts of Nursing-NUR 123
Reporting
 Summary Reports
 Walking Rounds
 Incident Reports
 Telephone Reports and Orders

31. Reporting
Summary Reports
 Commonly occur at change of shift (or when client is
transferred).
Walking Rounds
 Occur in the client’s room
 Include Nursing, physician, interdisciplinary team.
Incident Reports
 Used to document any unusual occurrence or accident
in the delivery of client care.

32. Concepts of Nursing-NUR 123
Reporting
Telephone Reports and Orders
 Report transfers, communicate referrals, obtain client
data, solve problems, inform a physician and/or client’s
family members regarding a change in the client’s
condition.
 Telephone orders are documented in the nurses’
progress notes and the physician order sheet.

33. 16-33
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Documenting a Telephone Order