I. Documentation and reporting are professional responsibilities of healthcare practitioners that provide written records of patient care, assessments, interventions, and responses. II. Effective documentation requires clear, concise, accurate, and organized recording of all patient information and events in a chronological fashion while maintaining confidentiality. III. The purposes of documentation include professional accountability, communication, care planning, education, research, and meeting legal standards.

1. DOCUMENTATION &
REPORTING
Arvind Joshi
Nursing tutor

2. Documentation & reporting in Nursing
• Documentation is the professional responsibility of all health care practitioners.
• Its provides a system of written records that reflect client care provided on the
basis of assessment data and the client’s response to interventions.
• Effective documentation requires clear, concise, accurate recording of all client care
and other significant events in an organized and chronological fashion.
• Nurses are bound by ethical codes and laws to treat all client information in a
confidential and professional manner.

3. 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. If its not charted, it is not done

5. Reporting
• is the oral, written, computer based communication intended to convey data regarding the
client’s (health status, needs, treatments, outcomes, and responses) to others health team
members.

6. Functions of Reporting
• helping to improve accountability
• showing how decisions related to patient care were
made
• supporting the delivery of services
• supporting effective clinical judgements and
decisions
• supporting patient care and communications
• making continuity of care easier
• providing documentary evidence of services
delivered
• promoting better communication and sharing of
information between members of the multi-
professional healthcare team
• helping to identify risks, and enabling early
detection of complications
• supporting clinical audit, research, allocation of
resources and performance planning, and
• helping to address complaints or legal processes

7. Purposes of Documentation:
Professional responsibility and accountability.
Communication,
Care planning,
Decision analysis
Education,
Research, auditing or statistics.
Meeting legal and practice standards,
Reimbursement.

8. Principles of effective documentation:
• Nursing notes must be logical, focused, and relevant to care, and must represent each phase in
the nursing process. Documentation requirements will differ depending on:
• a. Health care facility (hospital, nursing home, home health agency).
• b. Setting within the facility (e.g., emergency room, medical-surgical unit).
• c. Client populations (e.g., obstetrics, pediatrics, geriatrics).

9. Elements of Effective Documentation:
• Effective documentation requires:
• 1. Use of a common vocabulary (Proper use of spelling and grammar).
• 2. Identify the client, and write in ink.
• 3. Legibility and neatness.
• 4. Use of only authorized abbreviations and symbols. (ABG, ca, BSA, CABG, bpm, CBC, CPAP,
D5W)
• 5. Factual and time-sequenced organization.
• 6. Accurately including any errors that occurred.

10. 1. Use of Common Vocabulary:
• Nursing practice reflects the use of multiple terms for nursing interventions, preventing cross
institutional comparisons of nursing care.
• The current efforts under way to establish a taxonomy for nursing interventions determined by
specific nursing diagnoses will enhance the quality of documentation and support the efforts of
researchers.
• Use of common vocabulary will also improve intra team communication and lessen the chance
of misunderstandings

11. 2. Identify the client, and write in ink:
• every page of client record should have the client name on it. And every document, information
should be charted in ink or print out from computer.

12. 3. Legibility:
• Whatever is charted must be easily readable, without any chance of error.
• If your handwriting is not readable, print. If you make a mistake, do not erase or obliterate it;
draw one line through the erroneous entry and state the reason for the error, then sign and date
the correction.

13. 4. Abbreviations and Symbols:
• Facilities usually have a list of acceptable abbreviations and symbols, approved by the Medical
Records Committee, to be used when documenting information in the client’s record.
• Avoid abbreviations that can be misunderstood

16. 5. Factual and time-sequenced organization:
• a. Start every entry with the date and time.
• b. Chart in a chronological order assessment data, observation, intervention, and evaluation.
• c. Comply with the time frame indicated in the facility’s guidelines for documentation: for
example, the frequency of charting observations for a client with restraints or the time frame
within which the admit assessment must be completed.
• d. Chart in a timely fashion to avoid the omission of data; it is not a good practice to wait until
the end of the shift to chart on all the clients.
• e. Chart medications immediately after administration to avoid errors.
• f. Sign your name after each entry.
• g. When the nurse forgets to document significant data, it is appropriate and advisable to
include these data at a later date.

17. 6.Accuracy:
• Accuracy and objective data are crucial if the documentation is to be useful either clinically or
for research. Use factual, descriptive terms to chart exactly what was observed or done; for
example use correct spelling and grammar, and write complete sentences.

18. Types of Records
1. Patients Clinical Records
It is the record of events in the patient illness, progress in his or her
recovery and the type of care given by the hospital personnel.
2. Individual staff records.
A separate set of record is needed for staff, giving details of their
absences, their carrier development activities and a personnel note.
I

19. 3. Ward Records
These records are maintained in the each ward, such as
 Census records.
 Change in medical staff and non nursing personnel for the ward. (Duty roaster)
 Inventory and stock records
 Staffs Leave records
 Admission records
 Transfer records
 Discharge records
 Medicine records etc.

20. 4. Administrative records
These records are maintained purely for administrative purpose of the hospital or unit
 Legal documents: for the patients with poisoning, assault, rape, burns etc.
 Research or statistics data records
 Audit and nursing audit records
 Quality of care records
 Personnel performance. records
 Other administrative records

21. Type of reports
• 1. Change of shift reports
• A change of shift reports is given by a primary nurse to the nurse who assumes responsibility for
continuing care of the patient. The change of shift report might be given in written form or
orally.
• It provides basic identifying information such as patient condition, current appraisal of
each patients’ health status, current order by the physician, changes of medication,
intravenous fluids, diet, activity level.
Summary of each newly admitted patient.
Report on patients who have been transferred or discharged.

22. • 2. Transfer Report
• Transfer reports are provided by nurses when transferring a patient to another unit or to another
Ward/Hospital. Transfer reports contain similar information as bedside handoff reports, but are
even more detailed when the patient is being transferred to another Ward/Hospital.

23. • 3.Incident Report
• Incident reports, or sometimes called incident reporting, unusual occurrence report, or variance report;
is a commonly used term to describe safety event reporting. A safety event can occur when evidenced-
based best practice isn’t followed, resulting in harm or potential harm to a client.
• Some examples of safety events include accidental needlesticks, falls, medication errors which are the
number one cause of incidents, defective systems or equipment failure, missing client belongings
belongings and hospital acquired infections. Usually, an incident report is generated from the healthcare
healthcare worker.

24. Don’ts of documentation
o Leave a blank space for colleague to chart later
o Chart in advance of the event (procedure, medication)
o Use vague term
o Chart for someone else
o Record patient because its in their chart
o Skip a record even if requested by a supervisor
o Never guess about what is written.

25. Privacy and confidentiality
• All patients have a right of privacy and confidentiality
• All information about patient is considered private or confidential

26. General Documentation Guidelines:
Ensure that you have the correct client record or chart and that the client’s name and identifying
information are on every page of the record.
Document as soon as the client encounter is concluded to ensure accurate recall of data (follow
institutional guidelines on frequency of charting).
Date and time each entry.
Sign each entry with your full legal name and with your professional credentials, or per your
institutional policy.
Do not leave space between entries.

27. If an error is made while documenting, use a single line to cross out the error, then date, time,
and sign the correction (check institutional policy); avoid erasing, crossing out, or using
correction fluid.
Never change another person’s entry, even if it is incorrect.
Use quotation marks to indicate direct client responses (e.g., “I feel lousy”).
Document in chronological order (if chronological order is not used, state why).
Write legibly.

28. Use a permanent-ink pen (black is usually preferable because of its ability to photocopy well).
Document in a complete but concise manner by using phrases and abbreviations as
appropriate.
Document all telephone calls that you make or receive that are related to a client’s case.

29. Assessment-Specific Documentation
Guidelines
1. Record all data that contribute directly to the assessment (e.g., positive assessment findings
and pertinent negatives).
2. Document any parts of the assessment that are omitted or refused by the client.
3. Avoid using judgmental language such as “good,” “poor,” “bad,” “normal,” “abnormal,”
“decreased,” “appears to be,” and “seems.”
4. Avoid evaluative statements (e.g., “client is uncooperative,” “client is lazy”); cite instead
specific statements or actions that you observe (e.g., “client said ‘I hate this place’ and kicked
trash can”).

30. 5. State time intervals precisely (e.g., “every 4 hours,” “bid,” instead of “seldom,” “occasionally”).
6. Do not make relative statements about findings (e.g., “mass the size of an egg”) use specific
measurement (e.g. “mass 3cm )
7. Draw pictures when appropriate (e.g., location of scar, masses, skin lesion, 26 decubitus, deep
tendon reflex, etc.).
8. Refer to findings using anatomical landmarks (e.g., left upper quadrant [of abdomen], left
lower lobe [of lung], midclavicular line, etc.).

31. 9. Use the face of the clock to describe findings that are in a circular pattern (e.g., breast,
tympanic membrane, rectum, vagina).
10. Document any change in the client’s condition during a visit or from previous visits.
11. Describe what you observed, not what you did.

32. Thorough documentation provides
I. Accurate data needed to plan the client’s care in order to ensure the continuity of care.
II. A method of communication among the health care team members responsible for the
client’s care.
III. Written evidence of what was done for the client, the client’s response, and any revisions
made in the plan of care.
IV. Compliance with professional practice standards.
V. Compliance with accreditation criteria.
VI. A resource for review, audit, reimbursement, education, and research.
VII. A written legal record to protect the client, institution, and practitioner

33. Methods used for documentation
• 1. Narrative Charting:
• a. It is the traditional method of nursing documentation.
• b. Is a story format that describes the client’s status, interventions and treatments, and the
client’s response to treatments.
• c. Easy to use in emergency situations, in which a simple, chronological order is needed..

34. 2. Source-Oriented Charting:
• Is described as a narrative recording by each member (source) of the health care team on
separate records. Because each discipline has a separate record, care is often fragmented and
communication between disciplines becomes time-consuming

35. 3. Problem-Oriented Charting:
• Documentation is on the client’s problem, with a structured, logical format to narrative charting
called SOAP:
• a. S: subjective data (what the client or family states).
• b. O: objective data (what is observed/inspected).
• c. A: assessment (conclusion reached on the basis of data formulated as client problems or
nursing diagnoses).
• d. P: plan (actions to be taken to relieve client’s problem).
• SOAPIE and SOAPIER refer to formats that add: • I: intervention (measures to achieve an
expected outcome).• E: evaluation (effectiveness of interventions). • R: revision (changes from
the original plan of care).

36. 4. PIE Charting
• :Problem, intervention, evaluation (PIE) is an acronym for problem, intervention, and evaluation
of nursing care.
• In this the careplan is incorporated into the progress notes
• In this documentation , a patients assessment is done and documented at the beginning of each
shift using preprinted flow sheet, patient problems identified in this assessment are numbered
• Documented in progress notes, worked up using PIE format and evaluated each shift.

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38. 5.Focus Charting:
A method of identifying and organizing the narrative documentation of client concerns to include
data, action, and response. This method is not limited to client “problems” but allows for the
identification of all “concerns” such as a significant event (e.g., results of a diagnostic test).
Data: Subjective and/or objective information supporting the stated focus or
describing observations at the time of significant events.
Action: Nursing interventions performed, planned to be performed, and/or protocols
and procedures initiated.
Response: Description of individual's response to medical and/or nursing care. Statement
that the Action Plan of Care outcomes have been attained or are progressing
toward attainment.

40. 6.Charting by exception
• The CBE system has three key components:
• a. Flow sheets: Highlight significant findings and define assessment parameters and findings.
• b. Reference documentation: Is related to the standards of nursing practice.
• c. Bedside accessibility: Is related to the documentation forms.

42. 7.Computerized documentation and
electronic health record
• 1. call up the admission assessment tool on the computer screen and key in patient data
• 2. develop the care plan using computerized care plan available for each NANDA approved
diagnosis
• 3. add the patient database as new data are identified and modify the careplan accordingly
• 4. receive a work list showing treatment, procedure, and medication necessary for each patient
through each shift
• 5. document care immediately, using the computer terminal at bedside.

43. Benefits of HER
• Providing accurate, up to date and complete information about patients at point of care
• Enabling quick access to patient record for more coordinated, efficient care.
• Securely sharing electronic information with patients and other clinicians
• Helping providers more effectively diagnose patients, reduce medical errors and provide safer
care.
• Improving patient and provider interaction and communication
• Enable safer, more reliable prescribing.

44. Contd…
• Helping promote legible, complete documentation and accurate streamlined coding and billing
• Enhancing privacy and security of patient data
• Reducing cost through decreased paperwork, improved safety, reduced duplication of testing
and improved health.

45. Recommendation on HER standards in
India
• Never give your personal password or computer signature to anyone
• Don’t leave a computer terminal unattended after you have logged in
• Know and follow the correct protocol for correcting errors
• Never create, change or delete record unless you have authority to do so
• If you inadvertently delete a permanent record report it immediately
• Don’t leave information about patient displayed on a monitor where other may see it
• Follow the facility confidentiality protocol
• Never share any information to anyone using mail or any other mode to protect it from
unauthorized access.

46. • Remember every time you log into an electronic medical record with your login credentials, you
create a trail that can be traced, and you are liable for everything you document- or fail to
document.