Documentation

records and reports commonly used in nursing field.

1. DOCUMENTATION

2. DEFINITION Documentation is the written legal record of all pertinent interactions with the client -Assessing , diagnosing, planning, implementing and evaluating.

3. PURPOSES COMMUNICATION To promote continuity of care among departments To get a clear picture of client condition Ensure coordination of activities

4. QUALITY ASSURANCE To provide quality of care To ensure adequate care To make the changes To train the staffs To take remedies To improve the care

5. REIMBURSEMENT To provide cost awareness To help for insurance To find scarcity of resources

6. LEGAL ACCOUNTABILITY Evidence of court proceeding Protection for staffs Protection for client

7. RESEARCH To identify the problem Identify new ways of approaches To improve professional knowledge For determine the effectiveness of therapies

8. DIAGNOSTIC AND THERAPEUTIC ORDERS To carryout procedure It should signed by medical officer

9. ASSESSMENT Finding client history Subjective data Objective date

10. PLANNING Finding problems Planning the appropriate care

11. DECISION MAKING Identifying needs Prevent unnecessary use of care Financial management

12. EDUCATION Educational tool for students and health care team It help to learn about disease condition and treatments

13. VITAL STATISTICS To provide statistical information for health care agencies

14. PRINCIPLES Date and time Correct spelling Appropriateness Legal evidence Accuracy Completeness Legibility Corrections Omissions Signature Confidentiality

15. TYPES OF RECORDS Out patient and in patient record This contain data of the client, diagnosis, history, investigations, medications, treatment, progress etc Nurses recording large part of the client filled by the nurse regarding nursing measures like their observations and care with date & signature doctor’s order sheet prescriptions regarding medicine, investigations and diet Graphic chart of TPR patient TPR value are mentioned in this graph

16. Reports of lab examination ( blood, urine scanning etc) Diet sheets ( regarding food to be avoided and added) Consent forms ( before procedure, surgery, & anesthesia) Intake and output chart(intake is fluids taken and out put based on urine, vomiting amount) Registers (statistical reports of cases in hospital, death, birth registers also maintained) Medico legal cases documentation such as RTA, suicide attempts there is a need of police intimation

17. Medication records ( regarding name, dose, frequency of drugs with signature of nurses) Discharge and referral summaries ( regarding discharge and transferring of patiens ) Kardexes ( concise method of organizing patient data it consist of series of cards in a file) Flowshe ets ( other vise abbreviated progress notes give clear picture of patient condition)

18. Reporting Repots are essential tools of communication between the members of the health team.

19. Methods of Communication within the Health Care Team Change of shift reports This is the report given by a primary nurse to the nurse replacing him/her or by the charge nurse to the nurse who assumes responsibility for continuing care of the client. This report can be given in a written form or orally in a meeting or may be audiotaped

20. Forms of shift report Reports among the members of the nursing team Reports between the head nurse and her assistants Reports between the head nurse and nursing superintendent Reports to the physician Reports on mistakes, accidents, and complaints

21. Telephone / telemedicine reports with the technological advancement it is possible to give and take the telephonic order regarding client. Advantage is can deliver the message immediately disadvantage is no permanent record Incident reports it is the document of occurrence of anything out of the ordinary that result or potential harm to client, employee or visitors

22. Evaluation reports Monthly evaluation reports of students are sent to the principal by head nurse

23. Forms of records (documentation system) Source oriented record Problem oriented medical record (POMR) Problem, intervention, evaluation (PIE) Focus charting Charting by exception (CBE) Computerized documentation

24. Source oriented record It is a narrative recording by each member (source) of the health care team on separate document from admission to discharge Problem oriented medical record (POMR POMR organized around the client’s problem there are 4 components in POMR Database (assessments) Problem list (findings of assessments) Plan of care (plan for solve the problem) Progress note

25. Progress note format SOAP, SOAPIE, SOAPIER Subjective data Objective data Assessment Plan Intervention Evaluation Revision

26. PIE RECORD The main parts of this system are an integrated plan of care , assessment flow sheets, and nursing progress notes Example P- imbalanced nutrition I- encourage small and frequent diet E- glanced at patient food intake and weight gain

27. FOCUS CHARTING Focus charting includes data, action, response Data- subjective & objective Action- interventions Response – evaluation of nursing care

28. Charting by exception It is the documentation of only abnormal or significant finding

29. Computerized documentation Computerized clinical record system is being developed as a way to manage the huge volume of information required in a health care delivery

30. Issues in Computerized documentation Confidentiality is major concern Security Training of personnel Language used to name the nursing problem The individual should have log in and password for entering the computer record system

31. Advantages Legibility of information Less time consuming, and accuracy in record keeping Provide database for research and quality assurance Client information, requests and results are sent and received quickly Standard terminology improves communication Easy to transfer

32. Disadvantages Client may not have privacy if security measures are not used System failure may cause unavailability of information temporarily System is expensive Training is required