The document outlines the importance and principles of documentation and reporting in nursing, emphasizing the need for accurate and comprehensive records to ensure quality care and continuity. It details various types of records and reports, their purposes, and best practices for writing them, including the methods of documentation like narrative and problem-oriented charting. Additionally, it discusses the significance of incident reporting and the legal and communication roles of documentation in healthcare settings.

1. Documentation and Reporting
SONIA NOOR
BSN(Gen.)

2. Documentation
• Documentation is anything written or electronically
generated that described the status of a client or the
care or services given to that client.
• Documentation serves as a permanent record of client
information and care.

3. Purposes 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 serves as a evidence of care in a court of law.
• Shows the use of the nursing process.
• Provides data for quality assurance studies.
• Is a legal record that can be used as a evidence of
events that occurred or treatment given.
• Shows progress towards expected outcomes.

4. Principles of documentation
• Date and time
• Legibility
• Correct spelling
• Permanence
• Accurate
• Sequence
• Appropriateness
• Completeness
• Conciseness
• Organized
• Signature
• Confidentiality

5. Record
Definition
• Record is a formally legal, administrative tool that
permanently document information relevant to direct and
indirect patient care.
• Records are administrative devices used to collect and
classified information.

6. Purposes of records
• Supply data that are essential for programmed planning
and evaluation.
• Tools of communication between health workers , the
family & other development personnel.
• Effective health record show the health problem in the
family and other factors that affect health.
• Indicates plans for future.
• Help in research for improvement of nursing care.
• It provides baseline data to estimate the long-term
changes related to the services.

7. Characteristics of good records and
reporting
• Accuracy
• Conciseness
• Thoroughness
• Up to date
• Organization
• Confidentiality
• Objectivity

8. Principles of record writing
• Nurses should develop their own method 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.
• Record should be written immediately after an interview.
• Records are confidential documents.
• Accurately dated ,timed, and signed.
• Not include abbreviations ,jargon ,meaningless phrases.

9. Importance of Records in
Hospitals
For the individual and family
• Record serve to document the history of the client.
• Record assist in the continuity of care.
• Records serve as a evidence to support or to manage or to face the
legal questions that arise.
• Records serves to recognize the health needs and can be used as a
research and teaching tool.
For the doctor
• Serves as a guide for diagnosis , treatment ,follow up and
evaluation of services.
• Indicates progress and continuity of care.
• Help self evaluation of medical practice.

10. Continue…
• Protect the doctor in case of legal issues.
• Record may be used for teaching and research.
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 services for
further improvement.
• Serve as a guide for professional growth.
• Enable to judge the quality and quantity of work done.
• Serves as a communication tool between staff and other members
involved in care.
• Indicate plans for future.

11. Types of Records
• Patient clinical record
• Individual staff record
• Ward records
• Administrative records with educational value.

12. Reports
Definition
• Reports are information about a patient either written or oral.
(Sr. Nancy)
• A report is a summary of activities or observation seen, performed
or heard.
(potter & Perry)

13. Purposes
• Essential tool for communication.
• To show the kind and amount of services rendered over a specified
period.
• To illustrate progress in teaching goals.
• As an aid in studying health conditions.
• As an aid in planning.
• To interpret the services to the public and to the other interested
agencies.

14. Types of Report
• Oral report
oral reports are given when the 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.

15. Types of Reports in Nursing
Commonly used reporting in nursing.
• Change of shift reports (CSR)
• Transfer reports
• Incident reports
• Telephone reports

16. Change of shift reports
• 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.
• Example: if first shift nurse find a certain pain relief measures
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.

17. Transfer Reports
• Patients are often transfer from one unit to another to receive
different levels of care and treatment.
EXAMPLE : client transfer from an ICU or critical care units to general
nursing units when the client stable or no longer requires such intense
monitoring.

18. When giving a transfer report , following
information should be given:-
• Pt name , age , primary physician and medical diagnosis.
• Brief summary of progress up to the time of transfer.
• Patient health status (physical & psychological).
• Allergies (regarding drugs and medications).
• Current treatment status(iv fluids or any type of transfusions).
• Current nursing diagnosis or problem and care plan.
• Patient current vital signs and current thermodynamic status(temp .,
BP, PR,RR,Spo2,ECG etc.)
• Any critical assessment or procedure performed before going to
transfer a client.
• Need for any special equipment (cardiac monitor,suction
equipment).

19. Types of Incidents
• Falling from bed or in toilet.
• Needle stick injuries.
• Burns(hot applications or from another sources ).
• Drugs or medication administration errors.
• Misidentification of patients.
• Accidental omission of ordered therapies.

20. Incident Reports
• 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 reports are in major part of a unit quality improvement
program.

21. Guidelines to Report incident
• Describe in concise what exactly happens especially in objective
terms.
• Enumerate incident unit , time etc.
• Explain patient condition before and after incident.
• Describe any treatment given after incident.
• Record patient vital signs after incident.
• No nurse should blamed in an incident report.
• As soon as possible submit a report to the authority.

22. Telephone Reports
• Nurse inform physician or other health care team members
regarding changes in patient condition during caring and
communicate information to nurses on other units about client’s
transfer.
• Telephone reports must contain clear , accurate and concise.

23. Common record keeping forms
• Admission nursing history form
• Flow sheets and graphic records
• Patient care summary
• Standardized care plan
• Progress notes
• Discharge summary forms

24. Methods of documentation/recording
• Narrative charting
• Source-0riented charting
• Problem-oriented charting
• PIE charting
• Focus charting
• Charting by exception
• Computerized documentation
• Case management with critical paths

25. Narrative Charting (traditional
client record)
• Describes the client’s status , interventions and
treatments , response to treatments is in story format.
• It is now replaced by other formats.
Basic components of a traditional client
record:
• Admission sheet
• Physician’s order sheet
• Medical history
• Nurse’s notes
• Special record and reports (Xray , labs , refferals etc.)

26. Source-oriented charting
• Each person or department makes notations in a
separate sections of the client’s chart.
• Narrative recording by each member 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.
• Record become bulky
• For example the admission departments has an
admission sheet,nurses use the nurses notes ,
physicians have a physician notes etc.

27. Problem-oriented Medical
record(SOAP/IER format)
uses a structured , logical foramt called S.O.A.P/I.E.R
• S-subjective:what patient tells you..
• O-objective:what you observe,see.
• A-assessment:what you think is going on based on your
data.
• P-plan:what you are going to do.
• I-intervention:specific interventions implemented.
• E-evaluation:patient response to interventions.
• R-revision:change in treatment .
• uses flow sheets to record routine care.
• SOAP entires are usually made at least every 24 hours
on any unresolved problem.

28. 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 10:35am.
• E:patient reports pain 1/10 at 10:55 am.

30. Focus Charting
• A method of identifying and organizing the narrative
documentation of all client concerns.
• Uses a columner format within the progress notes to
distinguish the entry from other recordings in the
narrative notes(date & time , focus , progress notes).
• DATA-Sunjective or objective
• ACTION-Nursing intervention
• RESPONSE-Patient response to intervention
• Example: D-Complaining of pain at incision site , pain
scale;7/10
• A-repositioned for comfort.Demerol 50mg IM given
• R-states a decrease in pain,”feels much better”

31. Charting by Exception(CBE)
• The nurse documents only deviations from pre-
established norms (document only abnormal or
significant findings).
• Avoid lengthy , repetitive notes.

32. Computerized documentation
• Increase the qaulity of documentation and save time.
• Increase legibility and accuracy.
• Facillitates statistical analysis of data.

33. Case Management Process
• A methodology for organizing client care through an
ilness , using a critical pathway.
• a critical pathway is a multidisciplinary plan or tool that
specifies assessments , interventions , treatments and
outcomes of health related problems a cross a time line.