Documentation & Reporting In Nursing Practice

1. Documentation & Reporting
In Nursing Practice
Dr. Md Jahidul Islam
MBBS (DU), MPH (HM & HMD)
Data Scientist & Business Intelligence
(Netherlands)
Assistant Director (System Development &
Talent Management)
East West Medical College & Hospital
Dhaka, Bangladesh

2. Documentation
• Documentation is anything written or electronically
generated that describes the status of a client or the care or
services given to the client.
• Client” refers to individuals, families, groups, populations or
entire communities who require nursing expertise.
• Documentation serves as a permanent record of client
information and care.

3. Purpose of Documentation
• Provides a written record of the history, treatment, care,
and response of the patient while under the care of a health
care provider.
• Is a guide for reimbursement of costs of care.
• May serve as evidence of care in a court of law.

4. Purpose of Documentation
• Shows the use of the nursing process.
• Provides data for quality assurance studies.
• Is a legal record that can be used as evidence of events
that occurred or treatments are given.
• Contains observations by the nurses about the patient’s
condition, care, and treatment delivered.
• Shows progress toward expected outcomes.

5. Principles of Documentation
Date and Time
• Document the date and time of each recording.
• Record time in a conventional manner.
• Example: 8 am to 2 pm etc. is important not
only due to legal reasons but also for the
client’s safety.

6. Principles of Documentation
Legibility
• Entries must be legible and easy to read
• Writing must be clear
• Very important in recording numbers and medical
term

7. Principles of Documentation
Correct Spelling
• Correct spelling is essential for accuracy
• If unsure about the spelling use a dictionary or other
resource book

8. Principles of Documentation
Permanence
• Entry should be done in dark ink. It helps to identify
changes and allows duplication (Xerox)

9. Principles of Documentation
Accurate
• Use of exact measurement establishes accuracy; e.g
Intake of 450 ml of water then writing the adequate
amount of water
• Client name and identifying information is written on
each page
• Before making an entry in any chart make sure that it
is correct
• Chart is only your observation and actions to be
accountable.

10. Principles of Documentation
Sequence
• Document events in order of occurrence
• Such as Record assessments, then nursing
interventions, and then the client responses.
• Update or delete problems as needed.

11. Principles of Documentation
Appropriateness
• Record information pertaining to the client’s health
problems & care only.
• Avoid personal information that is inappropriate

12. Principles of Documentation
Completeness
• Documents all are necessary information
• It should give a clear picture of what took place
• Complete pertinent assessment data such as vital sign
wound drainage, client complaints, who was notified
and what interventions are carried out etc, are
recorded

13. Principles of Documentation
Conciseness (Brevity)
• Recording needs to be brief as well as complete to
save time in communication.
• The client’s name and the word client can be omitted.
• Eg. “perspiring profusely.
• Use accept abbreviations.

14. Principles of Documentation
Organized
• Information should have a logical manner
• Eg. description of pain, nurses assessment and
interventions, and the client response.
• This helps in preventing the omission of information
• Easy to read

15. Principles of Documentation
Signature
• Each recording is signed by the Nurse
• Signature includes the name and title
• In computerizing charting nurse will have this or her own
code

16. Principles of Documentation
Confidentiality
• All the client’s records are confidential file
• The information on the chart is personal as well as legal
• Record should not be copied without the permission of the
client
• Nurse should not allow any outsider to verify the client’s
record

17. The Following Information Should be
Included in the Chart
• A new or changed information
• Sign and symptoms
• Client behavior
• Nursing interventions
• Medications
• Physician’s order carried out
• Client teaching
• Client response

18. Record
• Record is a formal legal, administrative tool that
permanently documents information relevant to
direct or indirect patient care.
• Records are administrative devices used to collect
and classify information.

19. Record
• A record is a permanent written communication
that documents information relevant to a client’s
health care management.
• A record is a clinical, scientific, administrative, and
legal document relating to the nursing care given to
the individual family or community.
• Reports are oral or written exchanges of
information shared between caregivers or workers
in a number of ways

20. Purpose of Record
• Supply data that are essential for program planning
and evaluation.
• Provide the practitioner with data required for the
application of professional service for the
improvement of the family's health.
• Tools of communication between health workers,
the family & other development personnel.

21. Purpose of Record
• Effective health records show the health problem in
the family and other factors that affect health.
• Indicates plans for the future.
• Help in the research for the improvement of
nursing care.
• It provides baseline data to estimate the long-term
changes related to services.

22. Purpose of Keeping Records
• Communication
• Aids to diagnosis
• Education
• Documentation of continuity
• Research
• Legal documentation
• Individual case study

23. Criteria of Good Record
Keeping
Accuracy
Consciousness
Objectivity
Confidentiality
Thoroughness
Organization Up to Date

24. Principles of Record
Writing
• Nurses should develop their own methods of
expression and form in record writing.
• Written clearly, appropriately, and adequately.
• Contain facts based on observation, conversation,
and action.
• Select relevant facts and the recording should be
neat, complete, and uniform.

25. Principles of Record
Writing
• Valuable legal documents and so they should be
handled carefully, and accounted for.
• Record should be written immediately after an
interview.
• Records are confidential documents
• Accurately dated, timed and signed, Don’t use
abbreviations, jargon, or meaningless phrase

26. Importance of Records in
Hospital
For the Individual & the Family
• Records serve the documents the history of the
client
• Records assist in the continuity of care
• Records serve as the evidence to support or to
manage or face the legal questions that arise
• Records serve to recognize the health needs and
can be used as research and teaching tool

27. Importance of Records in
Hospital
For the Doctor
• Serves as guide for diagnosis, treatment, follow
up and evaluation of services
• Indicate progress and continuity of care.
• Help self evaluation of medical practice.
• Protect the doctor in case of legal issues. Records may
be used for teaching and research.

28. Importance of Records in
Hospital
For the Nurse
• Provide with documentation of services rendered, i.e.
shows health condition of the client.
• Provide data essential for planning and evaluation of
service for further improvement
• Serve as a guide for professional growth.
• Enable to judge the quality and quantity of work done.
• Serve as communication too between and other
members involved in care.
• Indicate plans for the future.

29. Type of Records
• Patients Clinical Record
• Individual Staff Record
• Ward Record
• Administrative Record with
Educational Value

30. Patients Clinical Record
• It is the knowledge of events in the patient
illness, progress in his or her recovery and
the type of care given by the hospital
personnel
• Scientific and legal
• Evidence to the patient that his/her case is
intelligently managed
• Avoid duplication of work
• Information for medical and legal nursing
research
• Aids in the promotion and health care
• Legal protection to the hospital doctor and
the nurse

31. Individual Staff Record
• A Separate set of records is needed
for staff, giving details of their
sickness and absences, their career
and development activities, and a
personal note.

32. Ward Record
• Reducing or increasing in beds
• Change in medical staff and nonnursing
personnel for the ward
• The introduction and pattern of support

33. Report
• Report can be complied daily, weekly, monthly,
quarterly, and annually.
• The report summarizes the services of the nurse
and/ or the agency.
• Reports may be in the form of an analysis of
some aspect of service.
• These are based on records and registers and so
it is relevant for the nurses to maintain the
records regarding their daily caseload, service
load, and activities.

34. Purpose
• A report is an essential tool for communication
• To show the kind and amount of services
rendered over a specific period
• To illustrate progress in teaching goals.
• As an aid in studying health conditionsition.
• As an aid in planning.
• To interpret the services to the public and to
the other interested agencies.

35. Types of Report
• Oral Report
• Written Report

36. Types of Report
• Oral Report
An oral report is given when information is for
immediate use and not for permanency
• Written Report
Written reports are to be written when the
information to be used by several personnel which
is more or less of permanent

37. Types of Report in Nursing
Change of Shift Report
(CSR)
Transfer Report
Incident Report
Telephone Report

38. Change of Shift Report
(CSR)
• This type of reporting is most commonly used.
• At the end of each shift nurses report information about
their assigned clients to the nurses working on the next
shift.
• The report provides continuity of nursing care among
nurses who are caring for a client.

39. • If the first shift nurse finds a certain pain relief
measure effective for a client, it is essential that
the information be related to the next nurse caring
for the client so that pain control intervention can
be continued.
Example of CSR

40. Guideline for Good CSR
• Treatment
• Admission
• Equipment losses and replacement
• Personal performance
• Other administrative records

41. Guideline for Good CSR
• Provide only essential background data on the
patient (e.g; name, age, gender, medical
diagnosis, and history)
• Describe objective measurements of patient
condition and response to health problems.
• Evaluate results of nursing or medical care
measures.

42. Guideline for Good CSR
• Be clear on priorities to which oncoming staff
must attend.
• Don’t review all routine care and procedure o
tasks.
• Don’t review all biographical data already
available in written form.
• Don’t use critical comments about patient
behavior.

43. Transfer Report
• Patients are often Transferred from one
unit to another to receive different
levels of care and treatment.
E.g; client’s transfer from an ICU or
critical care units to general nursing units
when the client stable or no longer requires
such intense monitoring.

44. Transfer Note
• Patient name, age, primary physician, medical
diagnosis
• Brief summary of the progress up to the time of
transfer
• Patient health status (Physical & Psychological)
• Allergies (Regarding drugs & medications)
• Current treatment status (IV fluids, blood
transfusion, and any other)
• Current nursing diagnosis or problem and care plan
• Patient’s current vital signs and hemodynamic status
(Temp, BP, HR, RR, SPO2, ECG)
• Any critical assessment or procedure performed
before going to transfer a client
• Need for any special equipment (Cardiac
monitoring, suction equipment etc)

45. Incident or Occurrence
Report
• An incident is any event that is not
consistent with the routine operation of health
care unit.
• Incidents are commonly occur when patient
under care within hospital settings.
• Incident report are in the major part of unit
quality improvement program

46. Types of Incident
• Falling from bed or toilet
• Needle stick injury
• Burns (hot application or other from of
source)
• Drugs or medications administration
errors
• Misidentification of patient
• Accidental omission of ordered
therapies

47. Bed Occupancy Rate (BOR)
Scenario 1:
In July 2022 at East West Medical College Hospital in the IPD (In Patient Department), inpatient days
were served with beds. Calculate inpatient bed occupancy rate in hospital
Scenario 1:
In August 2022 at East West Medical College Hospital in the IPD (In Patient Department), inpatient days
were served with beds. Calculate inpatient bed occupancy rate in hospital

48. Guidelines to Report
Incident
• Describe concisely what exactly happens
especially in objective term
• Enumerate incident unit and time
• Explain patient condition before and after
the incident (Physical & Psychological)
• Describe any treatment is given after
incident
• Record patient vital signs after the incident
• No nurse should blame in an incident
reports
• As soon as possible submit the report to the
authority.

49. Telephone Reports
• Nurses inform Physicians or other health
care team members regarding changes in
patient condition during care and
communicate information to nurses on
other units about client’s Transfer.
• Telephone reports also can utilize a
laboratory staff or other radiological staff
to provide immediate results about the
patient.
• Telephone reports must contain clear,
accurate, and concise.

50. Guidelines for Telephone
Reports
• It should be clearly the patient name, room,
unit number, IP number, and diagnosis
• Repeat the reports to avoid any
communication errors
• Use clarification questions to avoid
misunderstanding

51. Most Common Documents
in Patient Record
• Admission sheet
• Physician Order Sheet
• Nursing Admission Assessment
• Graphic Sheet and Flow Sheet- Vital Sign
and I/O Chart
• Medical History and Examination
• Nurses Note
• Medication Record
• Progress Notes
• Results from Diagnostic Reports
• Consent Form
• Discharge Summary
• Referral Summary

52. Computerized Documents
• Nurses use computers to store the client
database, add new data, create and revise
care plans, and document client progress.

53. Computerized Documents
Advantage
• Increase the quality of documentation and
save time
• Increases legibility and accuracy
• Facilitates statistical analysis of data
• The system links various sources of client
data

54. Computerized Documents
Disadvantage
• Clients’ privacy may be infringed on if security
measures are not used
• Breakdowns make information temporarily
unavailable
• The system is expensive
• Extended training period may be required when
a new and updated system is installed

55. Computerized Documents
Precautions
• Never share, change frequently
• Make sure the terminal can not be viewed
unauthorized person

56. Methods of Recording/
Documentation System
• There are several documentation systems for
recording patient data
• Regardless of whether documentation is
entered electronically or on paper, each health
care system selects a documentation system
that reflects its philosophy in nursing

57. Methods of Recording
• Narrative Charting
• Source-Oriented Charting
• Problem-Oriented Charting
• PIE Charting
• Focus Charting
• Charting by Exception (CBE)
• Computerized Documentation
• Case Management with Critical Path

58. Narrative Charting
• This is the most familiar method of
documenting nursing care
• It is a diary or story format in chronological
order
• It is used to document the patient’s status, care,
events, treatment, interventions, and patients
response to the interventions
Example
• 10/25/95 0730 Alert, oriented X 3. Responsive
to verbal stimulation. Breath sounds clear
bilaterally. Coughing and deep breathing
independently. I/V D/5/W at 100 cc’s infusion
with #18 angiocath in L forearm per pump. No
complaints of discomfort at this time. J. Doe
R.N.

59. Source Oriented Charting
• Each person or department makes notations in
a separate section/s of the client’s chart.
• Narrative recording by each member (source)
of the health care team on separate records.
• Most Traditional
• Different disciplines chart on separate forms
• Each reader must consult various parts of the
record to get a complete picture
• Records become bulky
• For example the admission department has an
admission sheet, nurses use the nurse’s notes,
physicians have physician’s notes, etc.

60. Problem Oriented Charting
• This style originated from the medical model
• Documentation is focused on patients’
problem
• It does not reflect the evaluation process of
care
SOAP Component
• S – Subjective data (What patient tell you)
• O – Objective data ( Includes measurements;
vital signs, laboratory results, your
observation/assessment, client response to
diagnosis & therapeutic measures)
• A – Assessment ( Interpretation and
conclusions from the subjective data; the
nursing diagnosis can be written in this part
• P – Plan (What you are going to do or what
you did, the plan of action is based on the
above data)

61. Problem Oriented Charting
SOAP Format
10/25/95 0800 #3 Orthostatic hypotension, risk of
injury
S –
O –
A –
P -

62. Nursing Progress
I – Intervention (Specific intervention
implemented)
E – Evaluation (Patients response to intervention)
R – Revision (Change in treatment)
• Uses flow sheet to record routine care
• SOAP entries are usually made at least every
24 hours or any unresolved problems

63. APIE Format
This is also a problem-oriented charting format
that arose from the nursing process
A – Assessment
P – Problems ( Usually numbered #1, #2 etc)
I – Intervention
E – Evaluation
APIE Format
A - #1 Supine BP 130/70. BP drops 20-30 mm hg
when he stands up
P - #2 Risk of injury related to dizziness
I - #1 Instructed to call for assistance when getting
OOB. All side rails up. Call bell placed within
reach
E - #1 Consistently call for assistance. Still
experiencing dizziness & orthostatic BP Change

64. Example of Focus Format
• Focus charting use three columns in the nurses
notes
DATE/TIME FOCUS NOTES
10/25/95 Dizziness
0800
D: Complaining of
Dizziness when getting
OOB. Supine BP 130/70
A: Instructed to call for
assistance when getting
OOB. All side rails up.
Call bell within the reach
R: Still experiencing
dizziness and orthostatic
BP changes

65. Charting by Exception
(CBE)
• With this documentation system, only significant
findings or exceptions to the norms are recorded
Three key components
1. Use of nursing flow sheets, physician order flow
sheets, graphic records, client teaching records,
and the patient’s discharge notes
2. Documentation by reference to standards of
nursing practice
3. Bedside accessibility of documentation forms. All
flow sheets are kept at the client’s bedside.

66. Minimizing Legal Liability
Through Effective Record
Keeping
• As the records are the proof of care and legal
documents the records have to be maintained
appropriately to avoid legal complications

67. The Nurse Has to Take the
Following Measures
• Keep the records under the safe custody of nurses
• No individual sheets should be separated
• Maintain the confidentiality of the information
• Don’t make accessible other patients and visitors
• Strangers are not permitted to read the records
• Records are not handed over the legal advisors
without written permission of the administration
• Handed carefully, not destroyed
• Identified with bio-data of the patients such as
name, age, admission number, UHID, diagnosis
• Never send outside of the hospital without the
written administrative permission

68. The Nurse Has to Take the
Following Measures
• Send the record to the medical record department
(MRD) for the further usage
• If You spill something on the chart, do not discard
notes. Recopy, and put original and copied sheets in
the chart. Write “copied” on a copy
• Do not scribble out charting
• Follow your facilities policy
• Don’t alter charting, it is a legal document.