The document discusses the importance of effective documentation in healthcare, detailing its role in communication, legal accountability, and professional standards. It outlines various methods of documentation, such as narrative and problem-oriented charting, as well as key elements like accuracy, confidentiality, and correction of errors. Additionally, it highlights the different types of patient records and the significance of thorough reporting to ensure quality patient care.

1. DOCUMENTATION
&
REPORTING
Mrs. Santhoshkumari. M,
MSc (N), PhD, MSc (Psy), PGDHM
Faculty in Nursing
College of Nursing,IGMC&RI
Puducherry

2. Documentation
Documentation is the process of
communicating in written form about
essential facts for the maintenance of
continuous history of events over a
period of time.
Recording & reporting are
the other ways of documentation.

3. 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. Purposes of
Health Care Documentation
Professional Responsibility and
Accountability
Communication
Education
Research
Legal and Practice Standards

5. 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. Elements of
Effective Documentation
Use of Common
Vocabulary
Legibility
Abbreviations and
Symbols
Organization &
Documenting a
Medication Error
Accuracy &
Confidentiality

7. • Use of Common Vocabulary
– Improves communication
– Lessens the chance of
misunderstanding between
members of the health team.
Elements of
Effective Documentation – Cont’d

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

9. Correcting a documentation error
Elements of
Effective Documentation – Cont’d

10. • Abbreviations and Symbols
– Always refer to the facility’s
approved listing.
– Avoid abbreviations that can be
misunderstood.
Elements of
Effective Documentation – Cont’d

11. Common Abbreviations

12. Elements of
Effective Documentation – Cont’d
• Organization
– Start every entry with the date and
time.
– Chart in chronological order.
– Chart medications immediately after
administration.
– Sign your name after each entry.

13. • Accuracy
– Use descriptive terms to chart
exactly what was observed or done.
– Use correct spelling and grammar.
– Write complete sentences.
Elements of
Effective Documentation – Cont’d

14. • 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
Elements of
Effective Documentation – Cont’d

15. • Confidentiality
– The nurse is responsible for
protecting the privacy and
confidentiality of client interactions,
assessments, and care.
Elements of
Effective Documentation – Cont’d

16. Nursing Documentation

17. Documentation Time
• Traditional time
– Two 12-hour revolutions; identified with
hour and minute, followed by a.m. or p.m.
• Military time
– Based on 24-hour clock; uses different four-
digit number for each hour and minute of
the day
o First two digits indicate hour within 24-
hour period
o Last two digits indicate minutes

18. Documentation Time (cont’d)

19. Documentation Time (cont’d)

20. 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

21. Methods of Documentation – Cont’d
• 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.

22. • 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….
Methods of Documentation – Cont’d

23. • 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.
Methods of Documentation – Cont’d

24. • 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 23.35 hours.
– E : Patient reports pain as 1/10 at 23.55 hours.
Methods of Documentation – Cont’d

25. • 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)
Methods of Documentation – Cont’d

26. Example of focus charting
Date & Time Focus: Progress notes:
05.Jan.2024 Acute pain related
to surgical
incision
D: Patient reports
pain as 7/10 on 0
to 10 scale
A: Given morphine
1mg IV at 23.35
R: Patient reports
pain as 1/10 at
23.55.
The progress notes are organized into:
Data (D),
Action (A),
Response (R).

27. Methods of Documentation –Cont’d
• Charting by Exception (CBE)
– The nurse documents only deviations
from pre-established norms
(document only abnormal or
significant findings).
– Avoids lengthy, repetitive notes.

28. • Computerized Documentation
– Increases the quality of
documentation and save time.
– Increases legibility and accuracy.
– Facilitates statistical analysis of data.
Methods of Documentation –Cont’d

29. • 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 across a time line.
Methods of Documentation –Cont’d

30. Medical or Nursing Records
• Medical or Nursing records are written
collections of information about a
person’s health, the care provided by
health practitioners, and the client’s
progress
Health
Records Client
Records

31. • Permanent account
• Sharing information
• Quality assurance
• Accreditation
• Reimbursement
• Education and research
• Legal evidence
Uses of Health Records

32. • Person’s health information
• Care provided by health
practitioners
• The client’s progress
• The plan for care
• Medication administration record
• Laboratory and diagnostic reports
Components of Medical Records

33. TYPE OF RECORDS
• WARD RECORDS
• NURSE’S RECORDS
• STUDENTS RECORDS
• STAFF RECORDS
• ACADEMIC & ADMINISTRATIVE
RECORDS.

34. PATIENT RECORD
• Patient record in hospital is maintained as he /she comes
to the hospital for availing preventive & therapeutic
services.
OUT-PATIENT RECORD
• They provide information about out patient referral
numbers, patients biodata, medical history past &
present, family history if any, investigation records,
diagnosis & treatment & frequency of visit.
IN-PATIENT RECORD
• Admission record
• Observation record
• Investigation record
• Intake- output record

35. Patient Records – Cont’d
• Treatment record
• Diet record
• Progress record
• Nurse’s record
• Discharge record
All these records kept in one folder for each
individual patient in the ward under the charge of the
ward sister till the patient is discharged. Thereafter, it is
transferred to the medical record section as per rules.

36. OTHER PATIENT RECORDS
• Other patient records:
- treatment book
- diet book
- admission register
- discharge & death register,
- notification form,
- inventories & related record forms,
- duty roaster etc.

37. NURSING SERVICE RECORD
These records are maintained by nursing service
department.
The nursing service records include the
• nurses duty register,
• master plan of nursing personnel,
• leave register which contains annual, casual,
& medical leave,
• nurses attendance register
• confidential records,
• correspondence with other hospitals,
agencies.

38. Forms for Recording Data
• Kardex
• Flow Sheets
• Nurses’ Progress Notes
• Discharge Summary

39. • 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.
Forms for Recording Data – Cont’d

40. Concepts of Nursing-NUR 123

42. 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, skin assessment record).
Forms for Recording Data – Cont’d

43. Nurses’ Progress Notes
• Used to document the client’s
condition, problems and
complaints, interventions,
responses, achievement of
outcomes.
Forms for Recording Data – Cont’d

44. Forms for Recording Data – Cont’d
• 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.

45. Reporting
• Verbal communication of data regarding
the client’s health status, needs,
treatments, outcomes, and responses
• Reporting is based on the nursing
process.

46. Types of Reporting
• Summary Reports
• Walking Rounds
• Incident Reports
• Telephone Reports and Orders

47. Types of Reporting – Cont’d
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.

48. Sample of written report
BED. NO. NAME & DIAGNOSIS DAY REPORT
41 Rani, F/56 yrs/ Bronchial
Asthma
New admission
The patient was received from
the emergency at 11am. On the
admission the patients general
condition was fair. Temp ,Pulse,
respiration were 99 degree F,
100/min & 26/min the patient
was having breathing problem,
had meals. all the medicines, as
prescribed by the doctor, are
given, o2 inhalation to be given
s.o.s.

49. Types of Reporting –Cont’d
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.

50. Documenting a Telephone
Order
16-50

51. DO'S AND DON'TS OF NURSING
DOCUMENTATION
• Nurses are well aware of the standard, which states
that if a certain matter affecting patient care is required
to be charted and it is not, the overwhelming
presumption is that it may not have been done.
• Good documentation will help you to defend yourself in
a malpractice lawsuit, it can also keep you out of court
in the first place.

52. DO’S
• Check that you have the correct chart before you begin
writing.
• Make sure your documentation reflects the nursing
process and your professional capabilities.
• Write legibly.
• Chart the time you gave a medication, the administration
route, and the patient's response.
• Chart precautions or preventive measures used, such as
bed rails.
• Record each phone call to a physician, including the
exact time, message, and response.
• Chart patient care at the time you provide it.
• If you remember an important point after you've
completed your documentation, chart the information with
a notation that it's a "late entry." Include the date and
time of the late entry.

53. DON’Ts
• Don't chart a symptom, such as "c/o pain,"
without also charting what you did about it.
• Don't alter a patient's record - this is a
criminal offense.
• Don't use shorthand or abbreviations that
aren't widely accepted.
• Don't write imprecise descriptions, such as
"bed soaked" or "a large amount."

54. Concepts of Nursing-NUR 123

55. Concepts of Nursing-NUR 123

56. Concepts of Nursing-NUR 123