RECORDING IN NURSING

1. RECORDING &
REPORTING
Anil Kumar BR
Lecturer
Medical surgical nursing

2. Introduction
■ Documentation within a client’s medical record is a vital aspect
of nursing care or practice.
■ The nursing documentation must be accurate,
comprehensive,and flexible.
■ Information in the client records provides a detailed account of
the level of quality of nursing care delivered to client’s. And
■ Accurate and effective documentation ensures continuity of
care, saves time and prevent duplication or error in the patient
care.

3. PurposesAnd importance of Records
A record is permanent written communication
that documents information relevant to a client’s
health care management.

4. Purposes or importance of records
■ Communication
■ Legal documentation
■ Nursing audit
■ Educational( records are useful in educational
purposes in various ways e.g a client diagnosis,s/s of
disease,sucessful and unsuccessful diagnostic
findings,and client behaviours.)

5. Purposes and importance of records
■ Financial billing
■ Nursing research
■ Improve quality of nursing care
■ Prevent errors and duplication and
■ Planning of care

6. Principles or guidelines for quality
documentation and recording
■ Nurses are need high-quality documentation and
recording are essential to enhance effective , accurate
and individualized patient care.
■ Quality documentation and recording have several
important characteristics.

7. Principles and guidelines for quality
documentation and recording.........
■ Factual
■ Accurate
■ Completness
■ Current
■ Organized
■ Timings

8. Factual.........
■ A factual record contains descriptive, objective
information about what a nurse sees,hears,fells,and
Smell’s.
■ E.g.A client BP is 80/50 mmHg, client
diaphoretic,restlesness, and HR is 102 and regular.*(the
use of inferences client appears to be in shock)
■ Without supporting factual data is not acceptable
because it can be misunderstood.

9. Accurate.......
■ The use if exact measurements establishes accuracy.
■ Use of an institution accepted abbreviations,symbols
and system of measures.

10. Completness......
■ The information will not be completed without full
information.
■ The information within a record entry or a report
needs to be complete, containing appropriate and
vital information otherwise it’s considered
incomplete.

11. Current.......
■ Timely documentation and recording is an vital
principles in documentation.
■ To increase accuracy , quality of care and decrease
unnecessary duplication and preventing errors it’s
essential to record timely.
■ For e.g a client BP is 140/90 when you’re admission
of some type of drugs the nude should records same.

12. Organized......
■ As a nurse you want communicate information in a
logical order.
■ For e.g an organized note describes the client’s
knowledge deficit, nurses assessment and interventions,
and the client’s response.
■ The nurse should applying theories, critical thinking,
EBP, and the nursing process gives logic and order to
nursing documentation.

13. Methods Of recording and
documentation
■ There are various documentation methods for
recording client’s data.
■ Each nursing services selected a documentation
system that reflects the philosophy if the instructions.

14. Methods of recording and
documentation
■ Narrative documentation
■ Problem oriented medical record (POMR)
1. Data base
2. Problem list
3. Nursing care plan
4. Progress notes (This are Major section of POMR)

15. Methods of recording and
documentation . Continue......
■ Source records
■ Charting by exception ( CBR)
■ Case management plan and critical pathways

16. Narrative documentation.....
■ It’s most common traditional method for recording
and documentation of nursing care.
■ It’s simple method
■ Use of a storyline format

17. Example for narrative notes

18. Problem oriented medical record (
POMR)
■ The POMR is a method of documentation that
emphasize the client’s problems.
■ Data are organized by problem or diagnosis
■ Basically each member if the health care team
contributes to a single list of identified client
problems.

19. The POMR Sections
■ DATA BASE (e.g all available assessment information
pertaining to the client such as history &physical
assessment, nutrition assessment, nurse’s admission
history, ongoing assessment and laboratory reports
etc)
■ The data base is foundation for identifying client
problems and planning of care.

20. The POMR Sections
■ PROBLEM LIST......
A) After analyzing data, health care team members
identify problems and make a single problem list
B) The problem list includes the client’s both
physiological, psychological,sicual ,
cultural,spirtual,developmental,and environmental
needs.

21. Nursing care plans....
■ Develop a care plan for each problem
■ Nurses document the plan of care in variety of
formats
■ Generally these plans of care include nursing
diagnosis,outcomes,and interventions.

22. Progress notes....
■ Health care team members monitor and recorded the
progress of a client’s problems.
■ Progress notes come in different formats or
structured notes.

23. Progress notes ... Continue...
■ One method formerly known as “ SOAP” stands for
S – Subjective data
O – Objective data
A – Assessment
P - plan

24. Continue...
■ A second progress note method is the PIE format.
■ It’s similar to SOAP charting in its problem oriented
nature.
P – Problem
I – Interventions
E - Evaluation

25. Continue...
A third narrative format is focus is charting.
1) It involves use of DAR.......
D – Data ( subj &obj)
A- Action or Nursing interventions
R- Response of the client *effectiveness

27. Source of records
■ In a Source record the client has a separate for each
discipline e.g nursing, medicine,social work or respiratory
therapy to record data.
■ One advantage of a source record is that caregivers can
easily locate the proper section of the record in which to
make entries.
■ A disadvantage of this method is that details a specific
problem are distributed through out the record.

28. Example for disadvantage of source
records
■ A nurse describes the character of abdominal pain
and use if non pharmacologic therapy such as
relaxation therapy and analgesic medications in the
nurse’s notes.
■ The physician’s notes describe the progress of the
client’s bowel obstruction and the plan for surgery in
separate section of the record for same client.

29. Charting by exception.... CBE
■ CBE focuses on documenting deviations from
the established norm or abnormal findings.
■ This approach reduces documentation time
and highlights trends .

30. Case management plan and critical
pathways....
■ The case management model of delivering care in
corporates a multidisciplinary approach to
documenting client care.

32. Jai hind .....jai Karnataka