The document outlines 14 principles of documentation for nursing records: 1) Date and time, 2) Legibility, 3) Correct spelling, 4) Permanence, 5) Accepted terminology, 6) Factual, 7) Accurate, 8) Appropriateness, 9) Completeness, 10) Current, 11) Conciseness, 12) Organized, 13) Signature, and 14) Confidentiality. It also describes different types of records including patient clinical records, individual staff records, ward records, and administrative records. The purposes of record keeping are also discussed.

1. RECORDS AND
REPORT
S

2. Principles of documentation
• 1. DATE & TIME
 Document date and time of each recording.
 Record time in conventional manner (E.g. 9am, 6pm etc) or
according to the 24 hour clock (military clock)
 Avoid recording in advance.
• 2. Legibility
 Entries must be legible and easy to read.
 Writing must be clear.
• Very important in recording numbers and medical
terms

3. Principles of documentation
• 3. Correct Spelling
 Correct spelling is essential for accuracy.
• 4. Permanence
 Entries should be done in dark ink.
 It helps to identify changes and allows duplication
• 5.Accepted Terminology
 Use commonly accepted abbreviations, symbols and
terms that are specified by the agency

4. Principles of documentation
• 6. Factual
 Descriptive objective information about what nurse
sees, hears, feels and smells.
 Use of inference without supporting data is not
acceptable.
 Vague terms like appear, seem or apparently is not
accepted.
 Include objective signs of problems.
 Subjective data is documented in client’s exact words
within quotation marks.

5. Principles of documentation
• 7.Accurate
 Use of exact measurement establishes accuracy.eg. Intake
450ml of water than writing adequate amount of water.
 Clients name and identifying information is written on each
page.
 Before making any entry in the chart makes sure that it is
correct.
 Chart only your observations and actions to be accountable.
• If any mistakes occur while recording, draw a line
through it and write above or next to original entry
with your initials or name. Do not erase, blot or use
correction fluids.

6. Principles of documentation
8. Appropriateness
Record information's pertaining to the client
health problems& care only.

7. Principles of documentation
9. Completeness
Document all necessary information's.
It should give a clear picture of what took
place Complete pertinent assessment data such
as vital signs, wound drainage, client
complaints, which was notified and what
interventions are carried out are recorded.

8. Principles of documentation
• 10. Current
 Timely entries are must Keeping record at bed side
may facilitate immediate documentation
• 11. CONCISENESS
 (BRIEVITY)Recording need to be brief as well as
complete to save time in communication
 Client’s name and the word client can be omitted E g.
“perspiring profusely. Respiration shallow. 28/mt ”
Use accepted abbreviations18. 13

9. Principles of documentation
• 12. ORGANIZED
 Information should have logical manner. E g.
description of pain, nurses assessment and
interventions and the client response
 This helps in preventing any omission of information.
Easy to read.
• 13. SIGNATURE
 Each recording is signed by the nurse Signature
includes the name and the title in computerized
charting nurse will have his or her own code.

10. Principles of documentation
• 14. Confidentiality
All the client’s record are confidential files
The information in the chart is personal as well
as legal.
Record shouldn't be copied without the
permission of the client
.Nurse should not allow any outsiders to verify
the client record.

11. Types of documentation:
RECORD
 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.
Conduct training and research work
Assess health problems.

12. DEFINITION:
◾ Records the memory of the internal and external
transactions of an organization. Records contain a
written evidence of the activities of an organization in
the form of letters, circulars, reports, contracts,
invoices, vouchers, minutes of meeting, books of
account etc.
[S.L.Geol, 2001 ]
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2

13. ◾ It is a written communication that
permanently documents information relevant
to a client’s health care management. It is a
continuing account of the client’s health care
needs
[Sr. Mary lucita ]
1
3

14. PRINCIPLES OF MAINTAINING
RECORDS:
Specific purpose which should be clearly
understood
Items on forms and in registers should be
conveniently grouped so as to make their
completion as easy as possible.
The wording should be easily understood, and
where doubt is likely to arise, instructions to
facilitate interpretation should be included.
14

15. Principles of maintaining records
(contnd…)
Records should permit some freedom of
expression.
Records which are required by the teaching
staff should be easily accessible to them.
Person responsible for maintaining records
should be aware of their particular
responsibility and every effort should be made
to keep records up to date and accurate.
15

16. Principles of maintaining records
(contnd…)
Provision for periodic review of all records to
ensure that they keep pace with the changing
needs of the programme.
Adequate supply of stationery to permit records
to be maintained on the proper forms and in the
proper registers at all times.
Sufficient number of filing cabinets
appropriate equipments to operate a
and
filing
system which is simple and safe and requires the
minimum possible time.
Adequate, safe, fireproof storage arrangements
16

17. General rules of recording
Keep separate records or charts for each individual
It’s a legal document, write it in English, clearly
accurately
Name, age, ward, date and inpatient number
should be written on each page
All entries should be signed.
Chart nursing care and medications and other
treatments only after giving them
It should be reliable and accurate
Information should be factual

18. General rules of recording….
Correct spelling
Nurses should not allow others to record
Use only standard abbreviations.
Do not use ditto marks or chemical formula in
charting
Each patient should have daily note ,written by
nurses on all shifts.
The information within a record should be
complete
Concise data are easily understand

19. General rules of recording……..
Lengthy notes are difficult to read
Record immediately after performing nursing
activities
It should have correctness
It should be organized in a logical format order
Nurses should maintain confidentiality of patient
record
Do not use blank space in the record.

20.  Accuracy
 Consciousness
 Thoroughness
 Up to date
 Organization
 Confidentiality
 Objectivity
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21. • Communication
• Aids to diagnosis
• Education
• Documentation of continuity
• Research
• Legal documentation
• Individual case study
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PURPOSE OF KEEPING RECORDS:

22. USES OF RECORDS
Show the health conditions as it is and as the
patient and family accepts it.
goals towards which means are to be directed.
prevents duplication of services and helps follow
up services effectively.
Helps the nurses to evaluate the care and the
teaching
Organization of work
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23. USES OF RECORDS (contnd….)
Serves as a guide for diagnosis
treatment and evaluation of services
indicate progress
Used in research
The health assets and needs of the
village area
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24. 1. Patients clinical record
2. Individual staff records
3. Ward records
4. Administrative records with educational
value.
TYPES OF RECORDS
24

25. Patient clinical record
operation and anesthesia
Out patient and inpatient record
Consent form for operation and anesthesia
Intake and output chart
Graphic charts for TPR
Diet chart
Doctors order sheet

26. 26
PATIENTS CLINICAL RECORDS
• 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.
a) Scientific and legal
b) Evidence to the patient the his /her case is
intelligently managed.
c) Avoids duplication of work.
d) Information for medical and legal nursing
research.
e) Aids in the promotion of health and care.
f) Legal protection to the hospital doctor and the
nurse

27. 10/24/2013 ANU JAMES 27
PATIENTS CLINICAL RECORDS (contnd..)
• NURSING ADMINISTRATOR’S RESPONSIBILITY?
 Protection from loss
 Safeguarding its contents
 Completeness
 Responsibility for nurses notes.
 Legal value of nurses notes.
 Admission record.
 Scientific value of the nurses notes
 Record of order carried out.

28. 28
INDIVIDUAL STAFF RECORDS.
• A separate set of record is needed for staff,
giving details of their sickness and absences,
their carrier and development activities and a
personnel note

29. 29
WARD RECORDS.
• Reducting or increase in beds.
• Change in medical staff and non nursing
personnel for the ward.
• The introduction and pattern of support.

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ADMINISTRATIVE RECORDS WITH
EDUCATIONAL VALUE.
• Treatments.
• Admissions.
• Equipments losses and replacements.
• Personnel performance.
• Other administrative records

31. TYPES OF RECORDS IN THE
DEPARTMENT OF PUBLIC HEALTH
31
• Cumulative or continuing records
• Family records
• Registers
• Reports

32. FILLING & ARRANGING OF RECORD
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• Alphabetically
• Numerically
• Geographically
• With index cards.

33. ALPHABETICALLY
• Dictionary order
• Encyclopaedic order
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34. Advantages and disadvantages of
alphabetically arrangement system
• Most people are familiar
• Staff should be able to learn
and become comfortable with
the system in a timely manner
• The need to shift the records
after purging records is
reduced
• Cross reference may be
avoided
Advantages Disadvantages
• system does not work well
with very large filing systems
• Color coding is more difficult
since you need to have 26
colors or combination of
colors to designate all the
letters of the alphabet
• Confidentiality is an issue
• Some of the rules of alpha
filing can be very confusing.
34

35. NUMERICALLY
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• Serial number
• Digit filing
GEOGRAPHICALLY
Information is arranged alphabetically
by geographical of place name.

36. 36
WITH INDEX CARDS
• An index card consists of heavy paper cut to a
standard size, used for recording and storing
small amounts of discrete data. It was
invented by Carl Linnaeus, around 1760.
Eg:- forms, case records and registers.
Diaries- diary of M & F
Return – monthly report of HW (M& F)
In addition each organization should maintain
• Cumulative records
• Family records

37. RECORD KEEEPING SYSTEM
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• Source records
• Problem oriented
• Nursing cardex
• Computerized information system

38. 10/24/2013 ANU JAMES 38
Computerized information system
3 major categories
1) Clinical system
2) Management information system
3) Educational system

39. GUIDELINES FOR DOCUMENTATION
AND RECORD KEEPING
39
The Nursing and Midwifery Council (NMC 2002)
has said that patient and client records should:
• be based on fact, correct and consistent
• be written as soon as possible after an event has
happened
• be written clearly and in such a way that the text
cannot be erased
• be written in such a way that any alterations or
additions are dated, timed and signed, so that the
original entry is still clear

40. GUIDELINES FOR DOCUMENTATION AND
RECORD KEEPING (contnd..)
40
• be accurately dated, timed and signed, with
the signature printed alongside the first entry
• not include abbreviations, jargon meaningless
phrases, irrelevant speculation and offensive
subjective statements
• be readable on any photocopies

41. IMPORTENCE OF RECORDS IN
HOSPITAL OR HEALTH CENTERS.
41
• INDIVIDUAL AND FAMILY
• FOR THE DOCTOR
• FOR THE NURSE
• FOR AUTHORITIES

42. REPORTS
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43. DEFINITION
A report containing information
against in a narrative graphic or tabular
form, prepared on periodic, receiving,
regular or as a required basis. Reports may
refer to specific periods, events,
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occurrence, or subject and may be
oral or
communicated or presented in
written form
[ Basvanthappa bt.2009 ]

44. DEFINITION (contnd..)
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Reports are oral or written
exchanges of information shared between
care givers of workers in a number of ways.
A report summarises the service of the
personnel and of the agency
[ Jean b. 2002 ]

45. PURPOSES
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• Report is an essential tool to 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 condition.
• As an aid in planning.
• To interpret the services to the public and to
the other interested agencies.

46. CRITERIA FOR A GOOD REPORT
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• made promptly.
• clear, concise, and complete.
• If it is written all pertinent, identifying data are
included-the date and time, the people
concerned, the situation, the signature of the
person making the report.
• It is clearly stated and well organized
• Important points are emphasized.
• In case of oral reports they are clearly expressed
and presented in an interesting manner.

47. REPORTS IN NURSING EDUCATION
47
• Factual data related to the students, staff,
clinical facilities, physical facilities,
administration and the curriculum
• Development made in the school programme
since the last report.
• Proposal and plans for future development.
• Problems encountered
• Recommendations

48. TYPES OF REPORTS
1. 24 hours reports
2. Census report
3. Anecdotal report
4. Birth and death report
5. Incidental report
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49. CLASIFICATION OF REPORTS BASED
ON TYPES
• Oral reports
• Written reports
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50. REPORTS USED IN HOSPITAL
SETTING:-
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• CHANGE – OF – SHIFT REPORTS
• TRANSFER REPORTS
• INCIDENT REPORTS
• LEGAL REPORTS

51. ADVANTAGES AND DISADVANTAGES
OF REPORTS
ADVANTAGES
• Monitoring operations
• Controlling
• Guide decision
• Employee motivation
• Performance evaluation
DISADVANTAGES
• It is time consuming.
• Expensive
• Reports can be biased
• Sometimes implementations
of the recommendations of a
report become unrealistic.
• Technical reports are not
easily understandable
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52. NURSES RESPONSIBILITY FOR RECORD
KEEPING AND REPORTING
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must be functional
Records and reports
accurate, complete, current organized and
confidential
• FACTS
• ACCURACY
• COMPLETENESS
• CURRENTNESS
• ORGANIZATION
• CONFIDENTIALITY

53. COMMON PROBLEMS THAT OCCUR
DURING REPORT WRITING.
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CONTENT AND ORGANIZATION
• Problem - No section headings
• Problem - missing items related to the
format
• Problem - lack of numbering

54. Common problems that occur during
report writing.(Contnd..)
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GRAMMAR, VOCABULARY, SENTENCE AND TONE.
OTHER PROBLEMS
• Incomplete sentences
• Confusing and unclear sentences.
• Miscommunication
• Too general
• Confidentiality.
• Missing information and facts.
• Wordiness.

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