documentation and reporting in Nursing and other students

documentation and reporting For nursing and other health care students

1. Concepts of Nursing-NUR 123
Documentation and Reporting
NUR 212-NUR211
Legal Aspects of Nursing

2. Concepts of Nursing-NUR 123
Documentation
Reporting and recording are the major
communication techniques used by
health care providers.

3. Concepts of Nursing-NUR 123
Documentation as
Communication
Documentation is defined as written
evidence of:
•The interactions between and among health
professionals, clients, their families, and
health care organizations.
•The administration of tests, procedures,
treatments, and client education.
•The results or client’s response to these
diagnostic tests and interventions.

4. Concepts of Nursing-NUR 123
Purposes of Health Care
Documentation
Professional Responsibility and Accountability
Communication
Education
Research
Legal and Practice Standards

5. Concepts of Nursing-NUR 123
Legal and Practice Standards
Informed consentmeans that the client
understands the reasons and risks of the
proposed intervention.
Witnessing confirms that the person who
signs the consent is competent.

6. Concepts of Nursing-NUR 123
Elements of Effective
Documentation
Use of Common Vocabulary
Legibility
Abbreviations and Symbols
Organization
Accuracy
Documenting a Medication Error
Confidentiality

7. Concepts of Nursing-NUR 123
Elements of Effective
Documentation
Use of Common Vocabulary
•Improves communication and lessens the
chance of misunderstanding between
members of the health team.

8. Elements of Effective
Documentation
Legibility
•Print if necessary.
•Do not erase or obliterate writing.
•State the reason for the error.
•Sign and date the correction.

9. Concepts of Nursing-NUR 123
Elements of Effective
Documentation
Correcting a documentation error

10. Concepts of Nursing-NUR 123
Elements of Effective
Documentation
Abbreviations and Symbols
•Always refer to the facility’s approved listing.
•Avoid abbreviations that can be
misunderstood.

11. Elements of Effective
Documentation
Organization
•Start every entry with the date and time.
•Chart in chronological order.
•Chart medications immediately after
administration.
•Sign your name after each entry.

12. Elements of Effective
Documentation
Accuracy
•Use descriptive terms to chart exactly what
was observed or done.
•Use correct spelling and grammar.
•Write complete sentences.

13. Elements of Effective
Documentation
Documenting a Medication Error
•Document in the nurses’ progress notes:
-Name and dosage of the medication
-Name of the practitioner who was notified of the error
-Time of the notification
-Nursing interventions or medical treatment
-Client’s response to treatment

14. Elements of Effective
Documentation
Confidentiality
•The nurse is responsible for protecting the
privacy and confidentiality of client
interactions, assessments, and care.

15. Methods of Documentation
Narrative Charting
Source-Oriented Charting
Problem-Oriented Charting
PIE Charting
Focus Charting
Charting by Exception (CBE)
Computerized Documentation
Case Management with Critical Paths

16. Methods of Documentation
Narrative Charting
•Describes the client’s status, interventions
and treatments; response to treatments is in
story format.
•Narrative charting is now being replaced by
other formats.

17. Methods of Documentation
Source-Oriented Charting
•Narrative recording by each member (source)
of the health care team on separate records.
•For example the admission department has an
admission sheet, nurses use the nurses’
notes, physicians have a physician notes,
etc….

18. Concepts of Nursing-NUR 123
Methods of Documentation
Problem-Oriented Charting
•Uses a structured, logical format called S.O.A.P.
-S: subjective data
-O: objective data
-A: assessment (conclusion stated in a form of nursing
diagnoses or client problems)
-P: plan
Uses flow sheets to record routine care.
SOAP entries are usually made at least every 24 hours
on any unresolved problem.

19. Concepts of Nursing-NUR 123
Methods of Documentation
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 2335.
•E : Patient reports pain as 1/10 at 2355.

20. Concepts of Nursing-NUR 123
Methods of Documentation
Focus Charting
•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)
•The progress notes are organized into: Data (D),
Action (A), Response (R).

21. Example of focus charting
Date & Time Focus: Progress notes:
05.Jan.2011 Acute pain related to surgical incision D: Patient reports pain as 7/10 on 0 to 10 scale.
A: Given morphine 1mg IV at 2335.
R: Patient reports pain as 1/10 at 2355.
Concepts of Nursing-NUR 123

22. Concepts of Nursing-NUR 123
Methods of Documentation
Charting by Exception (CBE)
•The nurse documents only deviations from
pre-established norms (document only
abnormal or significant findings).
•Avoids lengthy, repetitive notes.

23. Concepts of Nursing-NUR 123
Methods of Documentation
Computerized Documentation
•Increases the quality of documentation and
save time.
•Increases legibility and accuracy.
•Facilitates statistical analysis of data.

24. Concepts of Nursing-NUR 123
Methods of Documentation
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.

25. Concepts of Nursing-NUR 123
Forms for Recording Data
Kardex
Flow Sheets
Nurses’ Progress Notes
Discharge Summary

26. Concepts of Nursing-NUR 123
Forms for Recording Data
The Kardexis used as a reference throughout
the shift and during change-of-shift reports.
•Client data (e.g name, age, admission date, allergy)
•Medical diagnoses and nursing diagnoses
•Medical orders, list of medications
•Activities, diagnostic tests, or specific data on the pt.

27. Concepts of Nursing-NUR 123
Forms for Recording Data
Flow Sheets
The information on flow sheets can be formatted to
meet the specific needs of the client.
(e.g.: graphic sheets for vital signs, intake & output
record, MAR, skin assessment record).
Nurses’ Progress Notes
Used to document the client’s condition, problems
and complaints, interventions, responses,
achievement of outcomes.

28. Concepts of Nursing-NUR 123
Forms for Recording Data
Discharge Summary
•Client’s status at admission and discharge.
•Brief summary of client’s care.
•Interventions and education outcomes.
•Resolved problems and continuing need.
•Referrals.
•Client instructions.

29. Concepts of Nursing-NUR 123
Reporting
Verbal communication of data regarding the
client’s health status, needs, treatments,
outcomes, and responses
Reporting is based on the nursing process.

30. Concepts of Nursing-NUR 123
Reporting
Summary Reports
Walking Rounds
Incident Reports
Telephone Reports and Orders

31. Reporting
Summary Reports
Commonly occur at change of shift (or when client is
transferred).
Walking Rounds
Occur in the client’s room
Include Nursing, physician, interdisciplinary team.
Incident Reports
Used to document any unusual occurrence or accident
in the delivery of client care.

32. Concepts of Nursing-NUR 123
Reporting
Telephone Reports and Orders
Report transfers, communicate referrals, obtain client
data, solve problems, inform a physician and/or client’s
family members regarding a change in the client’s
condition.
Telephone orders are documented in the nurses’
progress notes and the physician order sheet.

33. 16-33Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Documenting a Telephone Order