Documentation & Reporting In Nursing Practice.pptx

Documentation & Reporting In Nursing Practice

1. Documentation & Reporting In Nursing Practice Dr. Md Jahidul Islam MBBS (DU), MPH (HM & HMD) Data Scientist & Business Intelligence (Netherlands) Assistant Director (System Development & Talent Management) East West Medical College & Hospital Dhaka, Bangladesh

2. Documentation Documentation is anything written or electronically generated that describes the status of a client or the care or services given to the client. Client” refers to individuals, families, groups, populations or entire communities who require nursing expertise . Documentation serves as a permanent record of client information and care.

3. Purpose 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 serve as evidence of care in a court of law .

4. Purpose of Documentation Shows the use of the nursing process. Provides data for quality assurance studies. Is a legal record that can be used as evidence of events that occurred or treatments are given . Contains observations by the nurses about the patient’s condition, care, and treatment delivered . Shows progress toward expected outcomes.

5. Principles of Documentation Date and Time Document the date and time of each recording. Record time in a conventional manner. Example : 8 am to 2 pm etc. is important not only due to legal reasons but also for the client’s safety.

6. Principles of Documentation Legibility Entries must be legible and easy to read Writing must be clear Very important in recording numbers and medical term

7. Principles of Documentation Correct Spelling Correct spelling is essential for accuracy If unsure about the spelling use a dictionary or other resource book

8. Principles of Documentation Permanence Entry should be done in dark ink. It helps to identify changes and allows duplication (Xerox)

9. Principles of Documentation Accurate Use of exact measurement establishes accuracy; e.g Intake of 450 ml of water then writing the adequate amount of water Client name and identifying information is written on each page Before making an entry in any chart make sure that it is correct Chart is only your observation and actions to be accountable.

10. Principles of Documentation Sequence Document events in order of occurrence Such as R e cord as s es sments , then nursi n g interventions, and then the client responses . Update or delete problems as needed.

11. Principles of Documentation Appropriateness Record information pertaining to the client’s health problems & care only. Avoid personal information that is inappropriate

12. Principles of Documentation Completeness Documents all are necessary information It should give a clear picture of what took place Complete pertinent assessment data such as vital sign wound drainage, client complaints, who was notified and what interventions are carried out etc , are recorded

13. Principles of Documentation Conciseness (Brevity) Recor d ing needs to b e brief a s well as complete to save time in communication. The client’s n ame an d the w ord client ca n be omitted. Eg. “perspiring profusely. Use accept abbreviations.

14. Principles of Documentation Organized Information should have a logical manner Eg. description of pain, nurses assessment and interventions, and the client response. This helps in preventing the omission of information Easy to read

15. Principles of Documentation Signature Each recording is signed by the Nurse Signature includes the name and title In computerizing charting nurse will have this or her own code

16. Principles of Documentation Confidentiality All the client’s records are confidential file The information on the chart is personal as well as legal Record should not be copied without the permission of the client Nurse should not allow any outsider to verify the client’s record

17. The Following Information Should be Included in the Chart A new or changed information Sign and symptoms Client behavior Nursing interventions Medications Physician’s order carried out Client teaching Client response

18. Record Record is a formal legal, administrative tool that permanently documents information relevant to direct or indirect patient care. Records are administrative devices used to collect and classify information.

19. Record A record is a permanent written communication that documents information relevant to a client’s health care management. A record is a clinical, scientific, administrative, and legal document relating to the nursing care given to the individual family or community. Reports are oral or written exchanges of information shared between caregivers or workers in a number of ways

20. Purpose of Record Supply data that are essential for program planning and evaluation. Provide the practitioner with data required for the application of professional service for the improvement of the family's health. Tools of communication between health workers , the family & other development personnel.

21. Purpose of Record Effective health records show the health problem in the family and other factors that affect health. Indicates plans for the future . Help in the research for the improvement of nursing care. It provides baseline data to estimate the long-term changes related to services .

22. Purpose of Keeping Records Communication Aids to diagnosis Education Documentation of continuity Research Legal documentation Individual case study

23. Criteria of Good Record Keeping Accuracy Consciousness Objectivity Confidentiality Thoroughness Organization Up to Date

24. Principles of Record Writing N u r s es should de v elop t h eir o w n methods of expression and form in record writing. Written clearly, appropriately, and adequately. C o ntain facts base d o n obser v at i o n, conversation, and action. Select relevant facts and the recording should be neat, complete, and uniform .

25. Principles of Record Writing Valuable legal documents and so they should be handled carefully , and accounted for. Record should be written immediately after an interview . Records are confidential documents Accurately dated, timed and signed , Don’t use abbreviations, jargon , or meaningless phrase

26. Importance of Records in Hospital For the Individual & the Family Records serve the documents the history of the client Records assist in the continuity of care Records serve as the evidence to support or to manage or face the legal questions that arise Records serve to recognize the health needs and can be used as research and teaching tool

27. Importance of Records in Hospital For the Doctor Serves as guide for diagnosis, treatment, follow up and evaluation of services Indicate progress and continuity of care. Help self evaluation of medical practice. Protect the doctor in case of legal issues . Records may be used for teaching and research .

28. Importance of Records in Hospital 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 service for further improvement Serve as a guide for professional growth . En a ble to judge t h e qua l i t y an d qua n tity of work done. Serve as communication too between and other members involved in care. Indicate plans for the future.

29. Type of Records Patients Clinical Record Individual Staff Record Ward Record Administrative Record with Educational Value

30. Patients Clinical Record 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 Scientific and legal Evidence to the patient that his/her case is intelligently managed Avoid duplication of work Information for medical and legal nursing research Aids in the promotion and health care Legal protection to the hospital doctor and the nurse

31. Individual Staff Record A Separate set of records is needed for staff, giving details of their sickness and absences, their career and development activities, and a personal note.

32. Ward Record Reducing or increasing in beds Change in medical staff and nonnursing personnel for the ward The introduction and pattern of support

33. Report Report can be complied daily, weekly, monthly, quarterly, and annually. The report summarizes the services of the nurse and/ or the agency. Reports may be in the form of an analysis of some aspect of service. These are based on records and registers and so it is relevant for the nurses to maintain the records regarding their daily caseload , service load, and activities.

34. Purpose A report is an essential tool for communication T o sh o w the kind and amount of services rendered over a specific period To illustrate progress in teaching goals. As an aid in studying health conditionsition . As an aid in planning. To interpret the services to the public and to the other interested agencies.

35. Types of Report Oral Report Written Report

36. Types of Report Oral Report An oral report is given when 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

37. Types of Report in Nursing Change of Shift Report (CSR) Transfer Report Incident Report Telephone Report

38. Change of Shift Report (CSR) This type of reporting is most commonly used . 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.

39. If the first shift nurse finds a certain pain relief measure 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. Example of CSR

40. Guideline for Good CSR Treatment Admission Equipment losses and replacement Personal performance Other administrative records

41. Guideline for Good CSR Provide only essential background data on the patient ( e.g ; name, age, gender, medical diagnosis, and history) Describe objective measurements of patient condition and response to health problems. E v al u ate results o f nurs i ng o r med i c al care measures.

42. Guideline for Good CSR B e clear o n pri o r iti e s to w h ich o n co m ing sta f f must attend. Don’ t review all routi n e care an d procedure o tasks. Don’ t rev i ew a ll b iograp h ical data a l r ea d y available in written form. Don’t use critical comments about patient behavior.

43. Transfer Report Patients are often Transferred from one unit to another to receive different levels of care and treatment. E.g ; client’s transfer from an ICU or critical care units to general nursing units when the client stable or no longer requires such intense monitoring.

44. Transfer Note Patient name, age, primary physician, medical diagnosis Brief summary of the progress up to the time of transfer Patient health status (Physical & Psychological) Allergies (Regarding drugs & medications) Current treatment status (IV fluids, blood transfusion, and any other) Current nursing diagnosis or problem and care plan Patient’s current vital signs and hemodynamic status (Temp, BP, HR, RR, SPO2, ECG) Any critical assessment or procedure performed before going to transfer a client Need for any special equipment (Cardiac monitoring, suction equipment etc )

45. Incident or Occurrence Report An incident is any event that is not consistent with the routine operation of health care unit. Incide n ts are c o m m o n ly o c cur w h e n p atient under care within hospital settings. Incident report are in the major part of unit quality improvement program

46. Types of Incident Falling from bed or toilet Needle stick injury Burns (hot application or other from of source) Drugs or medications administration errors Misidentification of patient Accidental omission of ordered therapies

47. Bed Occupancy Rate (BOR) Scenario 1: In July 2022 at East West Medical College Hospital in the IPD (In Patient Department), inpatient days were served with beds. Calculate inpatient bed occupancy rate in hospital Scenario 1: In August 2022 at East West Medical College Hospital in the IPD (In Patient Department), inpatient days were served with beds. Calculate inpatient bed occupancy rate in hospital

48. Guidelines to Report Incident Describe concisely what exactly happens especially in objective term Enumerate incident unit and time Explain patient condition before and after the incident (Physical & Psychological) Describe any treatment is given after incident Record patient vital signs after the incident No nurse should blame in an incident reports As soon as possible submit the report to the authority.

49. Telephone Reports Nurses inform Physicians or other health care team members regarding changes in patient condition during care and communicate information to nurses on other units about client’s Transfer. Telephone reports also can utilize a laboratory staff or other radiological staff to provide immediate results about the patient. Telephone reports must contain clear, accurate, and concise.

50. Guidelines for Telephone Reports It should be clearly the patient name, room, unit number, IP number, and diagnosis Repeat the reports to avoid any communication errors Use clarification questions to avoid misunderstanding

51. Most Common Documents in Patient Record Admission sheet Physician Order Sheet Nursing Admission Assessment Graphic Sheet and Flow Sheet- Vital Sign and I/O Chart Medical History and Examination Nurses Note Medication Record Progress Notes Results from Diagnostic Reports Consent Form Discharge Summary Referral Summary

52. Computerized Documents Nurses use computers to store the client database, add new data, create and revise care plans, and document client progress.

53. Computerized Documents Advantage Increase the quality of documentation and save time Increases legibility and accuracy Facilitates statistical analysis of data The system links various sources of client data

54. Computerized Documents Disadvantage Clients’ privacy may be infringed on if security measures are not used Breakdowns make information temporarily unavailable The system is expensive Extended training period may be required when a new and updated system is installed

55. Computerized Documents Precautions Never share, change frequently Make sure the terminal can not be viewed unauthorized person

56. Methods of Recording/ Documentation System There are several documentation systems for recording patient data Regardless of whether documentation is entered electronically or on paper, each health care system selects a documentation system that reflects its philosophy in nursing

57. Methods of Recording Narrative Charting Source-Oriented Charting Problem-Oriented Charting PIE Charting Focus Charting Charting by Exception (CBE) Computerized Documentation Case Management with Critical Path

58. Narrative Charting This is the most familiar method of documenting nursing care It is a diary or story format in chronological order It is used to document the patient’s status, care, events, treatment, interventions, and patients response to the interventions Example 10/25/95 0730 Alert, oriented X 3. Responsive to verbal stimulation. Breath sounds clear bilaterally. Coughing and deep breathing independently. I/V D/5/W at 100 cc’s infusion with #18 angiocath in L forearm per pump. No complaints of discomfort at this time. J. Doe R.N.

59. Source Oriented Charting Each person or department makes notations in a separate section/s of the client’s chart. N a r r ative recording b y ea ch member (source) of the health care team on separate records. Most Traditional Different disciplines chart on separate forms E a ch reader must consult various parts of the record to get a complete picture Records become bulky For example the admission department has an admission sheet, nurses use the nurse’s notes, physicians have physician’s notes, etc.

60. Problem Oriented Charting This style originated from the medical model Documentation is focused on patients’ problem It does not reflect the evaluation process of care SOAP Component S – Subjective data (What patient tell you) O – Objective data ( Includes measurements; vital signs, laboratory results, your observation/assessment, client response to diagnosis & therapeutic measures) A – Assessment ( Interpretation and conclusions from the subjective data; the nursing diagnosis can be written in this part P – Plan (What you are going to do or what you did, the plan of action is based on the above data)

61. Problem Oriented Charting SOAP Format 10/25/95 0800 #3 Orthostatic hypotension, risk of injury S – O – A – P -

62. Nursing Progress I – Intervention (Specific intervention implemented) E – Evaluation (Patients response to intervention) R – Revision (Change in treatment) Uses flow sheet to record routine care SOAP entries are usually made at least every 24 hours or any unresolved problems

63. APIE Format This is also a problem-oriented charting format that arose from the nursing process A – Assessment P – Problems ( Usually numbered #1, #2 etc ) I – Intervention E – Evaluation APIE Format A - #1 Supine BP 130/70. BP drops 20-30 mm hg when he stands up P - #2 Risk of injury related to dizziness I - #1 Instructed to call for assistance when getting OOB. All side rails up. Call bell placed within reach E - #1 Consistently call for assistance. Still experiencing dizziness & orthostatic BP Change

64. Example of Focus Format Focus charting use three columns in the nurses notes DATE/TIME FOCUS NOTES 10/25/95 Dizziness 0800 D: Complaining of Dizziness when getting OOB. Supine BP 130/70 A: Instructed to call for assistance when getting OOB. All side rails up. Call bell within the reach R: Still experiencing dizziness and orthostatic BP changes

65. Charting by Exception (CBE) With this documentation system, only significant findings or exceptions to the norms are recorded Three key components Use of nursing flow sheets, physician order flow sheets, graphic records, client teaching records, and the patient’s discharge notes Documentation by reference to standards of nursing practice Bedside accessibility of documentation forms. All flow sheets are kept at the client’s bedside.

66. Minimizing Legal Liability Through Effective Record Keeping As the records are the proof of care and legal documents the records have to be maintained appropriately to avoid legal complications

67. The Nurse Has to Take the Following Measures Keep the records under the safe custody of nurses No individual sheets should be separated Maintain the confidentiality of the information Don’t make accessible other patients and visitors Strangers are not permitted to read the records Records are not handed over the legal advisors without written permission of the administration Handed carefully, not destroyed Identified with bio-data of the patients such as name, age, admission number, UHID, diagnosis Never send outside of the hospital without the written administrative permission

68. The Nurse Has to Take the Following Measures Send the record to the medical record department (MRD) for the further usage If You spill something on the chart, do not discard notes. Recopy, and put original and copied sheets in the chart. Write “copied” on a copy Do not scribble out charting Follow your facilities policy Don’t alter charting, it is a legal document.