The document discusses guidelines for proper documentation and reporting in healthcare, including maintaining accurate, complete records for communication, education, and legal purposes. It also outlines the different types of reports like change of shift reports, incident reports, and legal reports that are important for monitoring quality of care. Proper documentation in medical records is essential for continuity of care, research, and evaluating health programs.

1. RECORD &
REPORT
(RECORDING & REPORTING)
Ram Sharan Mehta, Ph.D.
1

2. RECORDS
A record is a permanent written
communication that documents
information relevant to a client’s
health care management, e.g. a
client chart is a continuing
account of client’s health care
status and need.
-Potter and Perry
R S MEHTA, MSND 2

3. PURPOSES OF RECORDS
1.Supply data that are essential for programme
planning and evaluation.
2. To provide the practitioner with data
required for the application of professional
services for the improvement of family’s
health.
R S MEHTA, MSND 3

4. 3. Records are tools of communication
between health workers, the family, and
other development personnel.
4. Effective health records shows the health
problem in the family and other factors that
affect health.
5. A record indicates plans for future.
6. It provides baseline data to estimate the
long-term changes related to services.
R S MEHTA, MSND 4

5. Administrative purpose of clinical
records
• Legal documents: poisoning, assault, rape,
LAMA, burn etc.
• Research or statistics: rates
• Audit and nursing audit
• Quality of care
• Continuity of care
• Informative purposes: M E N census
• Teaching purpose of students
• Diagnostic purposes: test reports

6. Importance of Records in Hospital
1. For the individual and family:
- Serve the history of the client
- Assist in continuity of care
- Evidence to support if legal issues arise
- Assess health needs, research and
teaching.
R S MEHTA, MSND 6

7. 2. For the Doctor:
- Serve the guide for diagnosis, treatment,
follow-up and evaluation.
- Indicate progress and continuity of care.
- Self-evaluation of medical practice
- Protect doctor in legal issues
- Used for teaching and research
R S MEHTA, MSND 7

8. 3. For the nurses:
- Document nursing service rendered
- Shows progress
- Planning and evaluation of service for future
improvement
- Guide for professional growth
- Judge the quality and quantity of work done
- Communication tool between nurse and other
staff involved in the care.
- Indicate plan for future
R S MEHTA, MSND 8

9. 4. For authorities:
- Statistical information
- Administrative control
- Future reference
- Evaluation of care in terms of quality, quantity
and adequacy.
- Help supervisor to evaluate service
- Guide staff and students
- Legal evidence of service render by each
employee
- Provide justification of expenditure of funds.
R S MEHTA, MSND 9

10. Purposes of records: summary
1.COMMUNICATION
2.FINANCIAL BILLING
3.EDUCATION
4.ASSESSMENT
5.RESEARCH
6.AUDITING AND MONITORING
7.LEGAL ASPECT
R S MEHTA, MSND 10

11. Records in the nursing office & Unit
- Administrative records: Organogram, job
description, procedure manual
- Personnel records: personal files, records
- Patient related records: patients records send
to Medical director
- Leave record, duty roster, meeting minutes,
budget etc
- Miscellaneous: circular, round book, formats etc
R S MEHTA, MSND 11

12. PRINCIPLES OF RECORD WRITING
1. Nurses should develop their own
method of expression and form in
record writing.
2.Records should be written clearly &
appropriately.
3.Records should contain facts based on
observation, conversation and action.
R S MEHTA, MSND 12

13. 4. Select relevant facts and the recording
should be neat, complete and uniform
5.Records should be written immediately
after an interview.
6. Records are confidential documents.
R S MEHTA, MSND 13

14. FILLING OF RECORDS
Different systems may be adopted
depending on the purposes of the records
and on the merits of a system.
The records could be arranged:
– Alphabetically
– Numerically
– Geographically and
– With index cards
R S MEHTA, MSND 14

15. REGISTERS
• It provides indication of the total volume of
service and type of cases seen. Clerical
assistance may be needed for this.
Registers can be of varied types such as:
• immunization register,
• clinic attendance register,
• family planning register,
• birth register and
• death register.
R S MEHTA, MSND 15

16. GUIDELINES FOR QUALITY
DOCUMENTATION AND
REPORTING….
a) Factual basis
b) accuracy
c) completeness
d) accuracy
e) organization
f) confidentiality
R S MEHTA, MSND 16

17. NURSES RESPONSIBILITY FOR
RECORD KEEPING AND REPORTING
• Keep under safe custody of nurses.
• No individual sheet should be separated.
• Not accessible to patients and visitors.
• Strangers is not permitted to read records.
• Records are not handed over to the legal
advisors without written permission of the
administration.
• Handed carefully, not destroyed.
R S MEHTA, MSND 17

18. cont..
• Identified with bio-data of the patients
such as name , age, admission number,
diagnosis, etc. (Legal Issues?)
• Never sent outside of the hospital without
the written administrative permission.
R S MEHTA, MSND 18

19. Patient Verification
• Two identifiers: patient name and date
of birth
• Compare to ID band, consents, diagnostic
images, and all other patient
documentation related to the procedure

20. SYSTEM OF MEDICAL RECORD
• In the modern age, Medical Record has its
utility and usefulness and is a very broad
based indicator of patients care.
• The policy is to keep indoor patient Records
for 10 years
• The OPD registers for 5 years
• The record which is register for legal
purposes in Maintained for 10 years or till
final decision at the court of Law.
R S MEHTA, MSND 20

21. FUNCTIONS OF MEDICAL RECORD DEPARTMENT
1. Daily receipt of case sheets pertaining to
discharge and expired patients from various
wards, there checking and assembly.
2. Daily compilation of Hospital census report.
3. Maintains & retrieval of records for patient
care and research study.
4. Completion and Procession of Hospital
statistics and preparation on different
periodical reports on morbidity and
mortality.

22. 5. Online registration of vital events of
Birth & Death.
6. Issuing Birth & Death certificated up
to one year.
7. Dealing with Medico Legal records
and attending the courts on
summary.
8. Arrangement & Supervision of
enquiry and admission office.
R S MEHTA, MSND 22

23. REPORTS
R S MEHTA, MSND 23

24. • Reports can be compiled daily, weekly, monthly,
quarterly and annually.
• Report summarizes the services of the nurse and/
or the agency.
• Reports may be in the form of an analysis of some
aspect of a service.
• These are based on records and registers and so
it is relevant for the nurses to maintain the records
regarding their daily case load, service load and
activities.
• Thus the data can be obtained continuously and
for a long period.
R S MEHTA, MSND 24

25. NURSING REPORTS
o Reports are information about a patient
either written or oral.
-sr. Nancy
o A report is a summary of activities or
observations seen, performed or heard.
-Potter and Perry
R S MEHTA, MSND 25

26. PURPOSES OF WRITING REPORTS
• To show the kind and quantity of service
rendered over to a specific period.
• To show the progress in reaching goals.
• As an aid in studying health conditions.
• As an aid in planning.
• To interpret the services to the public and to
other interested agencies.
R S MEHTA, MSND 26

27. TYPE OF REPORTS
1)Change of shift report
2) telephone reports
3)Telephone orders
4)Transfer reports
5)Incident reports
6)Legal reports
R S MEHTA, MSND 27

28. CRITERIA OF GOOD REPORT
Can be made promptly
Clear, concise and complete
All pertinent, identifying data included
Mention all people concerned, situation
and signature of person making report
Easily understood
Important points are emphasized
R S MEHTA, MSND 28

29. Key Messages
• Written policies and procedures are
the backbone of the quality system
• Complete quality assurance records
make quality management possible
• Keeping records facilitates meeting
program reporting requirements
29

30. • Records and reports revels the
essential aspects of service in
such logical order so that the
new staff may be able to
maintain continuity of service
to individuals, families and
communities.
R S MEHTA, MSND 30

31. Thank You
R S MEHTA, MSND 31

32. Extra Slides
R S MEHTA, MSND 32

33. What are Electronic Medical Records?
The IOM 2003 Patient Safety Report describes an EMR as
encompassing:
– “a longitudinal collection of electronic health information
for and about persons
– Immediate electronic access to person- and population-
level information by authorized users;
– Provision of knowledge and decision-support systems
that enhance the quality, safety, and efficiency of patient
care and
– Support for efficient processes for health care delivery.”

34. What are Electronic Medical Records?
The 1997 IOM report “The Computer-Based Patient
Record: An Essential Technology for Health Care”
defines an EMR as:
“A patient record system is a type of clinical
information system, which is dedicated to
collecting, storing, manipulating, and making
available clinical information important to the
delivery of patient care.
The central focus of such systems is clinical data
and not financial or billing information.”

35. What are Electronic Medical Records?
The American Health Information Management
Association defines three essential capabilities of an
EMR:
1. To capture data at the point of care,
2. To integrate data from multiple internal and
external sources, and
3. To support caregiver decision making.

36. Implementing an EMR in LTC
Leadership Support
Pre- Change Peer Mentor & Go Live & Account
Implementation Management Training Support Management
Optimum User Adoption
& Customer ROI

37. Records Should be Permanent,
Secure, Traceable
• Permanent: • Traceable:
– Sign and date every
– Keep books bound
record
– Number pages
– Use permanent ink
– Control storage
• Secure:
– Maintain confidentiality RECORDS
– Limit access
– Protect from
environmental hazards
37

38. Summary
• What is the difference between a document and
a record?
• What are some examples of documents and
records?
• Name examples of information not found in a
manufacturer product insert.
• What are some key features of SOPs?
• What are some tips for good record-keeping?
• How should records be maintained?
• How are test site records reported in your
country?
38

39. Transfer of Patients
• Transferring unit will change the status of any
appropriate interventions from “Active” to
“Complete” by clicking in the Status column
– Completed Admissions Documentation
– System Flowsheet
• Receiving unit stops all nursing orders initiated
in order entry, enters transfer orders according
to policy and procedure, and the nurse will add
on the correct system flowsheet for the patient
on the intervention list using the “Add
Intervention” Function

40. Order Entry
• All paper physician order sheets
must be faxed to pharmacy upon
admission
• Pharmacy will enter any medications and IVs
into Meditech – the list of current medications
can be viewed in the EMR by clicking on the
Medications tab
• All non-medication orders will be entered by
the nurse or secretary into the Meditech order
entry system

41. Order Entry
• It is the RN’s responsibility to verify ALL orders
(lab, radiology, nursing, etc.) are entered into
Meditech from the Physician Order Sheet (Use
Order History in the EMR)
• Initial each individual order with red ink after
verification that the order is in Meditech
• After all orders have been entered and verified, a
Kardex will be printed from the Meditech desktop
using the Reports button

42. Verification of Physician Orders
• For ancillary department orders requiring
pager notification (Respiratory Therapy)
the time of the page is written on the order
sheet next to the order
• Co-sign each set of
physician orders with
initials, title, date, and time

43. 24-hour Chart Checks
• Performed on 11pm – 7am shift
• Review ALL orders written during the
previous 24 hours and verify they are in
Meditech by accessing the EMR (order
history section, sorted by date)
• Sign entire physician’s order sheet with
name/initials, title, date and time in red
ink

44. Blood Administration
Documentation
• Blood Transfusions are documented as an Intervention
Set, which can be added using the “Add Intervention” link
on the Intervention worklist (search for “set”)
• The set is comprised of:
– Blood Administration Verification (completed just prior to starting
infusion)
– Blood Product Infusion (start time and initial rate)
– Infusion Changes (any rate changes during infusion)
– Blood Product Completion (completed at end of infusion)
– Blood Vital Signs (baseline vitals taken at start, then q15min x 2
after initiation, then hourly)

45. Documentation of Wounds
• Wounds are documented as an Intervention Set,
which can be added using the “Add Intervention”
link on the Intervention worklist (search for “set”)
• The set is comprised of:
– Wound / Pressure Ulcer Status Assessment: for initial,
weekly, and change of status wound documentation
(more detailed)
– Wound Care / Dressing Change Assessment: for daily
documentation of dressing changes (focused
assessment specifically for dressing changes)

46. Critical Lab Values
Documentation
• The lab will call the nurse (as well as the
physician) responsible for taking care of the
patient with the critical lab value
• The telephonic critical result, upon receipt, will
be read back to the technologist/technician and
documented as having been read back. If that
does not happen, the technologist/technician will
request that the nurse receiving the critical result
read it back.

47. Critical Lab Values
Documentation
Procedure
1. Verify the result by verbally reading the result
back to the technologist/technician
2. Notify the nurse assigned to the patient of the
critical result if she/he was not the one to
receive the telephonic notification.
3. Document receiving the phone call about the
critical value, the critical result, and what you
did about the result on the Critical Lab Values
Intervention in Meditech PCS.

48. Computer Downtime
• In the event of a computer downtime, the
documentation system reverts back to paper (all
paper forms will be stocked on units)
• For downtime less than 4 hours (med/surg) and 2
hours (critical care), information that is recorded on
paper will need to be entered into PCS
• For downtime exceeding 4 hours (med/surg) and 2
hours (critical care), the paper system will replace
PCS until the end of the shift and until the system is
back up – the only data that must be re-entered into
PCS in this case are the Vital Signs and the I&O, so
the EMR record will be accurate

49. Discharge Documentation
• The physician writes the discharge instructions
• The nurse is responsible for reviewing all instructions
with the patient and obtaining the patient signature
• Carenotes can be printed out from the Infoweb (click on
Micromedix link to access) for patient education
• The nurse should make sure the patient understands the
complete list of medications the patient is to take once
being discharged (compared to any medications the
patient was taking on admission), as part of the
medication reconciliation process
• Original form goes to medical records and a copy is
given to the patient upon discharge

50. What stays on paper?
• Consent forms
• Admission / Transfer Summaries
• OR/Recovery Documentation
• Physician Order Sheets
• Documentation During Patient Codes
• Pre-op Checklist
• Discharge Instructions
• Labor Event – Triage up until Delivery
• Monitoring Strips

51. Documentation Details
• A nurse can skip a question on an
assessment if he/she is unable to assess
the question due to patient condition or if
the question is not applicable for the
patient at that time
• Any retrospective documentation can be
entered up to 3 days following patient
discharge. ?

52. Documentation Details
• Changes to documentation may only be
made by the person who recorded the
documentation
• Partially documented entries,
documentation editing, and undoing
documentation can be completed by
clicking in the History column for the
appropriate intervention

53. SYSTEM OF MEDICAL RECORD
• DEFINITION
Medical Record of the patient stores the
knowledge concerning the patient and his care. It
contains sufficient data written in sequence of
occurrence of events to justify the diagnosis,
treatment and outcome.
In the modern age, Medical Record has its utility
and usefulness and is a very broad based
indicator of patients care.

54. Flow of Medical Record :-
The flow chart of inpatient Medical Record is as
under :-
Wards
Central Admission
Office
Medical Record Department
1. Assembling Afetr completion of
Reccords
2. ADMN. &
Hospital statistics prepared
Discharge Monthly/Yearly
analysis
3. Storage Area Medical Record is filled for perusal of
Patients/claims/research purposes.

55. FILING OF MEDICAL RECORDS
• The inpatients Medical Record is filed by the
serial numbers assigned at central Admitting
Office.
• The Record is bound in bundles 100 each
and are kept year wise according to the serial
number.
RETENTION OF MEDICAL RECORD
• The policy is to keep indoor patient Records
for 10 years
• The OPD registers for 5 years
• The record which is register for legal
purposes in Maintained for 10 years or till
final decision at the court of Law.

56. TYPES OF RECORDS
1. Cumulative or continuing records
• This is found to be time saving, economical and also it is helpful to review the total history of an individual
and evaluate the progress of a long period. (e.g.) child’s record should provide space for newborn, infant
and preschool data.
• The system of using one record for home and clinic services in which home visits are recorded in blue and
clinic visit in red ink helps coordinate the services and saves the time.
R S MEHTA, MSND 56

57. 2. Family records
• The basic unit of service is the family. All
records, which relate to members of family,
should be placed in a single family folder. This
gives the picture of the total services and helps
to give effective, economic service to the family
as a whole.
• Separate record forms may be needed for
different types of service such as TB, maternity
etc. all such individual records which relate to
members of one family should be placed in a
single family folder.
R S MEHTA, MSND 57