6. PURPOSE OF RECORDING AND REPORTING
I. COMMUNICATION
II. EDUCATION
III. ASSESSMENT
IV. RESEARCH
V. AUDITING AND
MONITORING
VI. LEGAL ADMINISTRATIVE
7. APPLICABLE ITEMS
a) Case file
b) Nursing initial assessment ,re assessment ,nursing care plan and RN handover check
book
c) Nurses progress notes
d) Departmental registers
e) Clinical check lists
8. PROCEDURE
I. Nurses are the custodian of all the patient and
departmental documents.
II. Charge nurse /shift in charge nurses are
responsible for departmental records and
administrative data
III. RN is responsible to close file with relevant
data.
IV. Ensure that nursing clinical documentation
includes:
All aspects of the nursing process such as
9. PROCEDURE
Clear and concise statement of patient status ( physical ,
psychological and spiritual)
Details of clinical assessment and monitoring
The care/service provided ( interventions, advocacy
counselling, consultation and teaching )
Evaluation of outcomes, including the patient’s response
and further plan
Discharge plan
10. PROCEDURE
Plan of care
it should be clear ,concise and accurate as per the
patient condition / needs
Details of risk assessment ,admission. Transfer ( in
and out )and discharge information ,patient and family
education ,incident reports ,medication administration
,verbal orders and telephone orders.
I. Ensure that the nurses progress note is
Clear, concise.unbiased and accurate
11. PROCEDUE
Legible with correct spellings.
Without blank space , abbrevations, symbols and acronyms
Avoid generalized statements and no use of whitener
I. If any mistake /error : cross through the words with a single line above the
line write as mistake /error and write name and signature of the nurse along
with the date and time
II. For any change /additions in the documents , obtain a formal permission
from the hospital management
III. Nurse should document the details on timely ,chronologically and
frequently