Documentation and reporting

unit 6 documentation and reporting

1. Documentation and reporting Unit - VI Mr. gulam ahmad raza Nursing tutor

2. Documentation Documentation is anything written or electronically generated that describes the status of a client or the care or services given to that client. (Perry, A.G., Potter, P.A., 2010 ). “ 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. Purposes 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. 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 given. Contains observations by the nurses about the patient’s condition, care, and treatment delivered. Shows progress toward expected outcomes.

5. Principles of Documentation 1. DATE and TIME Document date and time of each recording. Record time in conventional manner. Example: 8 am to 2 pm etc. this is important not only due to legal reasons but also for the client’s safety.

6. 2.LEGIBILITY Entries must be legible and easy to read. Writing must be clear. Very important in recording numbers and medical terms.

7. 3.CORRECT SPELLING Correct spelling is essential for accuracy. If unsure about the spelling use a dictionary or other resource book.

8. 4.PERMANANCE Entries should be done in dark ink. It helps to identify changes and allows duplication (Xerox ).

9. 5. ACCURATE Use of exact measurement establishes accuracy. E.g . 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 make sure that it is correct. Chart only your observations and actions to be accountable .

10. 6.SEQUENCE Document events in order of occurrence. Eg . Record assessments, then nursing interventions and then the client responses. Update or delete problems as needed.

11. 7. APPROPRIATENESS Record informations pertaining to the client health problems & care only. Avoid personal informations that are in appropriate .

12. 8 . COMPLETENESS Document all necessary informations . It should give a clear picture of what took place. Complete pertinent assessment data such as vital signs, wound drainage, client complaints, who was notified and what interventions are carried out etc. are recorded.

13. The following informations should be included in the chart : A new or changed information Signs and symptoms Client behavior Nursing interventions Medications Physician’s orders carried out Client teaching Client response

14. 9 . 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. Eg . “perspiring profusely. Use accept abbreviations.

15. 10. ORGANIZED Information should have logical manner Eg . description of pain, nurses assessment and interventions and the client response. This helps in preventing any omission of informations . Easy to read.

16. 11. 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.

17. 12.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.

18. Record Definition Record is formally legal, administrative tool that permanently document information relevant to direct or indirect patient care. Records are administrative devices used to collect and classified information.

19. 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. Purposes of Records Supply data that are essential for programme planning and evaluation . Provide the practitioner with data required for the application of professional services for the improvement of family's health. Tools of communication between health workers, the family & other development personnel.

21. Effective health records show the health problem in the family and other factors that affect health. Indicates plans for future. Help in the research for 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. Characteristics of good recording and reporting

24. Principles of record writing Nurses should develop their own method of expression and form in record writing. Written clearly, appropriately and adequately. Contain facts based on observation, conversation and action. Select relevant facts and the recording should be neat, complete and uniform.

25. Valuable legal documents and so it should be handled carefully, and accounted for. Records should be written immediately after an interview. Records are confidential documents. Accurately dated, timed and signed. Not include abbreviations, jargon, meaningless phrases.

26. Importance of Records in Hospital For the Individual and Family Records serve to document the history of the client. Records assist in the continuity of care. Records serve as 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 a research and teaching tool.

27. 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. 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 services for further improvement. Serve as a guide for professional growth. Enable to judge the quality and quantity of work done. Serve as communication tool between staff and other members involved in care. Indicate plans for the future.

29. For Authorities Provide the management with statistical information necessary for decision in regard to utilization of resources, planning for administrative control and future references. Help the supervisor evaluate the services rendered, teaching done and a person’s action and reactions.

30. TYPES OF RECORDS Patients clinical record Individual staff records Ward records Administrative records with educational value.

31. 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.

32. 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.

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

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

35. 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.

36. 2) Family records All records, which relate to members of family, should be placed in a single family folder. 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.

37. REPORTS 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 .

38. Definition Reports are information about a patient either written or oral. (Sr . Nancy) A report is a summary of activities or observations seen, performed or heard . (Potter and Perry) 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 ]

39. PURPOSES 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.

40. TYPES OF REPORT ORAL REPORTS WRITTEN REPORTS

41. ORAL REPORTS Oral reports are given when the information is for immediate use and not for permanency. WRITTEN REPORTS Written reports are to be written when the information to be used by several personnel which is more or less of permanent.

42. TYPES OF REPORTS IN NURSING Commonly used reporting in nursing. Change-of-shift reports (CSR ) Transfer reports Incident reports Telephone reports

43. CHANGE-OF-SHIFT REPORTS ( CSR ) ) This type of reporting most commonly using. At the end of each shift nurses report information about their assigned client’s to the nurses working on the next shift. The report provides continuity of nursing care among nurses who are caring for a client .

44. EXAMPLE FOR CSR If 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 .

45. GUIDELINES FOR GOOD CSR Provide only essential background data on patient (e.g. name , age, gender, Medical diagnosis , and history) Describe objective measurements about patient condition an response of health problem. Evaluate results of nursing or medical care measures.

46. Be clear on priorities to which oncoming staff must attend. Don’t review all routine care and procedure or tasks. Don’t review all biographical data already available in written form. Don’t use critical comments of patient behavior .

47. TRANSFER REPORTS Patient’s are often Transfer 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 .

48. WHEN A GIVING A TRANSFER REPORts , THE FOLLOWING INFORMATION SHOULD BE GIVEN: - Patient name , age, primary Physician and Medical diagnosis. Brief summary of progress up to the time of transfer. Patient health status (physical & psychological). Allergies (regarding drugs and medications).

49. Current treatment status (IV fluids , blood transmission any other). Current nursing diagnosis or problem and care plan . Patient current vital sings and heamodynamic status (Temp., BP HR , RR, SpO2, ECG etc.). Any critical assessment or procedure performed before going to transfer a client. Need for any special equipment (Cardiac monitoring, suction equipment etc.).

50. INCIDENT OR OCCURRENCE REPORTS An incident is any event that is not consistent with the routine operation of health care unit. Incidents are commonly occur when patient under care within hospital settings. Incident reports are in major part of a unit quality improvement program.

51. TYPE OF INCIDENTS Falling from bed or in toilet. Needle stick injuries. Burns (hot Application or from other sources ). Drugs or medications administration errors. Misidentification of patient. Accidental omission of ordered therapies.

52. GUIDELINES TO REPORT INCIDENT Describe in concise what exactly happens especially in objective terms. Enumerate incident unit, time etc. Explain patient condition before and after the incident (physical & psychological ). Describe any treatment is given after incident. Record patient vital sings after incident. No nurse should blamed in an incident reports. As possible soon submit a report to the authority .

53. TELEPHONE REPORTS Nurse’s inform Physician or other health care team members regarding changes in patient condition during caring and communicate information to nurses on other units about client’s Transfer. Telephone reports also can be utilizes a laboratory staff or other radiological staff to providing immediate results about patient. Telephone reports must contain clear, accurate, and concise .

54. GUIDELINES FOR TELEPHONE REPORTS It should be clearly patient name, room, unit no, IP number and diagnosis. Repeat the reports any communication error occur. Use clarification questions to avoid misunderstanding .

55. COMMON RECORD-KEEPING FORMS A variety of paper or electronic forms are available for the type of information nurses routinely document. The categories within a form are usually derived from institutional standards of practice or guidelines established by accrediting agencies .

56. Admission Nursing History Forms A nurse completes a nursing history form when a patient is admitted to a nursing unit. The form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems .

57. Flow Sheets and Graphic Records Flow sheets allow you to quickly and easily enter assessment data about a patient, including vital signs and routine repetitive care such as hygiene measures, ambulation, meals, weights, and safety and restraint checks. Flow sheets help team members quickly see patient trends over time and decrease time spent on writing narrative notes. Critical and acute care units commonly use flow sheets for all types of physiological data .

58. Patient Care Summary or Kardex Kardex forms have an activity and treatment section and a nursing care plan section that organize information for quick reference. An updated Kardex eliminates the need for repeated referral to the chart for routine information throughout the day .

59. The patient care summary or Kardex includes the following information : Basic demographic data (e.g., age, religion) Health care provider’s name Primary medical diagnosis Medical and surgical history Current orders from health care provider (e.g. dressing changes, ambulation, glucose monitoring) Nursing care plan Nursing orders (e.g., education sessions, symptom relief measures, counseling) Scheduled tests and procedures Allergies.

60. Standardized Care Plans Some institutions use standardized care plans. The plans, based on the institution’s standards of nursing practice, are pre-printed, established guidelines used to care for patients who have similar health problems. After completing a nursing assessment, the nurse identifies the standard care plans that are appropriate for the patient and places the plans in his or her medical record. The nurse modifies the plans to individualize the therapies.

61. Progress Notes Progress notes made by nurses provide information about the progress a client is making toward achieving desired outcomes .

62. Discharge Summary Forms When you leave hospital, you should have a discharge summary given to you . A discharge summary is a letter written by the doctor caring for you in hospital.

63. It contains important information about your hospital visit, Including: Why you came into hospital The results of any tests you had The treatment you received Any changes to your medication What follow-up you need

64. Most Common Documents In Patient Record: Admission sheet Physician’s order sheet Nurse’s admission assessment Graphic sheet and flow sheet- vital signs, I/O chart Medical history and examination Nurses ’ notes Medication records Progress notes Results from diagnostic tests consent forms Discharge summary Referral summary

65. Computerized documentation Nurses use computers to store the client’s database, add new data, create and revise care plans, and document client progress .

66. ADVANTAGES Increases the quality of documentation and save time. Increases legibility and accuracy. Facilitates statistical analysis of data. The system links various sources of client information.

67. DISADVANTAGES Client’s privacy may be infringed on if security measures are not used. Breakdowns make information temporarily unavailable. The system is expensive. Extended training periods may be required when a new or updated system is installed .

68. PRECAUTIONS Password:- Never share, Change frequently. Make sure terminal cannot be viewed by unauthorized persons .

69. Guidelines for reporting FACTUAL BASIS ACCURACY COMPLETENESS CURRENTNESS ORGANIZATION CONFIDENTIALITY

70. FACTUAL BASIS:- Information about clients and their care must be functional. A record should contain descriptive, objective information about what a nurse sees, hears, feels and smells. ACCURACY:- A client record must be reliable. Information must be accurate so that health team members have confidence in it.

71. COMPLETENESS:- The information within a recorded entry or a report should be complete, containing concise and thorough information about a client care or any event or happening taking place in the jurisdiction of manger. CURRENTNESS:- Delays in recording or reporting can result in serious omissions and untimely delays for medical care or action legally, a late entry in a chart may be interpreted on negligence.

72. ORGANIZATION:- The nurse or nurse manager communicates information in a logical format or order. Health team members understand information better when it is given in the order in which it is occurred. ONFIDENTIALITY:- Nurses are legally and ethically obligated to keep information about client’s illnesses and treatments confidential.

73. COMMUNICATION WITH IN THE HEALTH CARE TEAM In today’s health care system, delivery processes involve numerous interfaces and patient handoffs among multiple health care practitioners with varying levels of educational and occupational training. During the course of a 4-day hospital stay, a patient may interact with different professionals, including physicians, nurses, technicians, and others .

74. Lack of communication creates situations where medical errors can occur. These errors have the potential to cause severe injury or unexpected patient death. Effective communication takes place along two approaches: 1 . Recording 2 . Reporting

75. Patient identification and demographic data Informed consent for treatment and procedures Admission data Nursing diagnosis or nursing care plan Record of nursing care treatment and evaluation Medical history All records contain the following information:

76. Medical diagnosis Therapeutic orders Medical and health discipline progress notes Physical assessment findings Diagnostic study results Patient education Summary of operative procedures Discharge plan and summary

77. Reports are oral, written, or audio taped exchanges of information among caregivers. Common reports given by nurses include change-of- shift reports, telephone reports, hand-off reports, and incident reports. A health care provider calls a nursing unit to receive a verbal report on a patient’s condition . The laboratory submits a written report providing the results of diagnostic tests and often notifies the nurse by telephone if results are critical .

78. Team members communicate information through discussions or conferences. For example, a discharge planning conference involves members of all disciplines (e.g., nursing, social work, dietary, medicine, and physical therapy) who meet to discuss the patient’s progress toward established discharge goals .

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

80. 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 Paths

81. 1. Narrative Charting (TRADITIONAL CLIENT RECORD) Describes the client’s status, interventions and treatments, response to treatments is in story format. Narrative charting is now being replaced by other formats.

82. Five Basic components of a Traditional Client Record Admission sheet Physician’s order sheet Medical history Nurse’s notes Special records and reports (referrals, X-ray, reports, laboratory findings, report of surgery, anesthesia record, flow sheets, vital signs, I&O, medication.

83. 2. Source-Oriented Charting Each person or department makes notations in a separate section/s of the client’s chart. Narrative recording by each member (source) of the health care team on separate records. Most Traditional Different disciplines chart on separate forms Each 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 nurses notes, physicians have a physician notes, etc .

84. 3. Problem-Oriented Medical Record( POMR )/(SOAP/ IEr format) Uses a structured, logical format called S.O.A.P./I.E.R S – Subjective. What patient tells you. O – Objective. What you observe, see. A – Assessment. What you think is going on based on your data. P – Plan. What you are going to do.

85. NURSING PROCESS I – Intervention (specific interventions implemented) E – Evaluation. Patient response to interventions. R – Revision. Changes in treatment. Uses flow sheets to record routine care. SOAP entries are usually made at least every 24 hours on any unresolved problem.

86. 4. PIE Charting P : Problem statement I : Intervention E : Evaluation Example : P : Patient reports pain at surgical incision as 7/10 on 0 to 10 scale I : Given morphine 1mg IV at 10:35 am. E : Patient reports pain as 1/10 at 10:55 am.

87. Pain scale

88. 5. Focus Charting (DAR) A method of identifying and organizing the narrative documentation of all client concerns. Uses a columnar format within the progress notes to distinguish the entry from other recordings in the narrative notes (Date & Time, Focus, Progress note ).

89. DATA – Subjective or objective that supports the focus (concern) ACTION – Nursing intervention RESPONSE – Patient Response to intervention Example: D – Complaining of pain at incision site, pain scale: 7/10 A – Repositioned for comfort. Demerol 50 Mg IM given. R – States a decrease in pain, “feels much better.”

90. 6. Charting by Exception (CBE) The nurse documents only deviations from pre-established norms (document only abnormal or significant findings). Avoids lengthy, repetitive notes .

91. 7. Computerized Documentation Increases the quality of documentation and save time. Increases legibility and accuracy. Facilitates statistical analysis of data .

92. 8. Case Management Process A methodology for organizing client care through an illness, using a critical pathway. A critical pathway is a multidisciplinary plan or tool that specifies assessments, interventions, treatments and outcomes of health related problems a cross a time line .

93. 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.

94. The nurse has to take the following measures : Keep the records under safe custody of nurses. No individual sheet should be separated. Maintain the confidentiality of the information Don’t make accessible to other patients and visitors .

95. Strangers are not permitted to read records. Records are not handed over to 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, diagnosis, etc. Never sent outside of the hospital without the written administrative permission .

96. Send the records to medical record department (MRD) for the further usage. You spill something on the chart, do not discard notes. Recopy, put original and copied sheets in chart. Write “copied” on copy. Do not scribble out charting. Follow your facilities policy. Do not alter charting, it is a legal document.

97. Maintenance Of Computerized Records : Maintain the confidentiality of the information. Never disclose the password to any others Don’t delete any information from the system unless you are authorized to do.

98. THANK YOU