The document discusses various methods of nursing documentation and recording. It describes the purposes of accurate nursing documentation as communication, legal documentation, nursing audits, education, financial billing, nursing research, and improving the quality of care. The principles of quality documentation include being factual, accurate, complete, current, organized and timely. Common documentation methods discussed are narrative notes, problem-oriented medical records (POMR), source records, charting by exception, and case management plans.

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