DOCUMENTATION AND RECORDING.pptx

Nursing foundation

1. PREPARED BY IDUNA SOPHIA DCOUTO ASSOCIATE PROFESSOR NHCON DOCUMENTATION AND RECORDING

2. DOCUMENTATION Documentation is anything written or printed on which you rely as record or proof of patient actions and activities.- Potter and Perry The process of making and entry on a client record is called recording, charting or documenting. - Kozier

3. REPORTING A report is oral, written or computer based communication intended to convey information to others. RECORD It is also called a chart or client record, is a formal, legal document that provides evidence of a clients care and can be written or computer based.

4. PURPOSES OF REPORTS AND RECORD 1. Communication 2. Planning client care 3. Legal documentation 4. Research 5. Education 6. Auditing Health Agencies 7.Reimbursement 8. Health Care Analysis

5. CONFIDENTIALITY

6. TYPES OF CLIENT RECORDS/COMMON RECORD KEEPING FORMS MEDICAL RECORDS 1. Patient identification and demographic data 2. Present complaints 3.Informed consent for treatment and procedure 4. Admission nursing history 5.Family history 6. Physical examination findings 7. Medical history 8. Tentative diagnosis 9. Medical diagnosis 10.Theraputic orders

7. Con’t 11. Treatment given 12. Medical progress notes 13. Supportive care given 14. Reports of diagnostic studies 15. Final diagnosis 16. Patient education 17. Summary of operative pocedures 18. Discharge plan and summary 19. Any specific special instructions

8. COMMON NURSING RECORDS/ FORMATS FOR NURSING DOCUMENTATION 1. Nursing assessment 2. Nursing care plans 3. Kardexes

9. CON’T 4. Flow sheets 5. Graphic records 6. Fluid balance record 7. Medication administration form 8.Skin assessment record 9. Progress notes

10. METHODS /SYSTEMS OF DOCUMENTATION/RECORDING 1. SOURCE – ORIENTED RECORD 2. PROBLEM – ORIENTED MEDICAL RECORD (POMR)/PROBLEM ORIENTED RECORD (POR) 1.Database 2.Problem list 3. Plan of care 4. Progress notes 3. PIE 4. FOCUS CHARTING

11. CON’T 5. CHARTING BY EXCEPTION (CBE ) 1. Flow sheets 2. Standards of nursing care 3. Bedside access to chart forms 6. COMPUTERIZED DOCUMENTATION/ ELECTRONIC MEDICAL RECORDS (EMR) 7. CASE MANAGEMENT 8. PERSONAL HEALTH RECORDS (PHRs)

12. LEGAL GUIDELINES FOR DOCUMENTATION Date and Time Timing Legibility Permanence Accepted terminology Correct spelling Signature Accuracy Sequence Appropriateness Completeness Conciseness Legal Prudence Factual

13. REPORTING Reports are oral written or audio taped exchange of information between caregivers Purposes of writing reports To identify the quality of service T o show the progress in reaching goal T o study health conditions T o interpret the services to the public and to other agencies

14. CRITERIA OF A GOOD REPORT Made promptly To be clear, concise and complete All identified data to be included Easily understood Important points to be emphasized

15. GUIDELINES FOR REPORTING Factual Accurate Complete Current issue Organisation

16. TYPES OF REPORT Change of shift report/hand off communication Transfer reports Telephone reports Incident report/ accident report Intra division reports Inter departmental reports Care Plan Conference Nursing rounds