principles of reporting

PRESENTED BY ATTAH B.K FOR NURSES OF FMC KEBBI

1. PRINCIPLES OF RECORDING AND REPORTING PAPER PRESENTED BY: ATTAh b kashim TO: nursing department of fmc birnin kebbi AUGUST 9, 2019

2. OUTLINE Introduction Definitions of: Recording Reporting Purpose of recording and reporting P principles of recording & reporting Summary Conclusion

3. INTRODUCTION: Historically, records of events have been for thousands of years in one form or another. Amongst the earliest are  cave painting ,  runic alphabets  and  ideograms . Ways of recording text suitable for direct reading by humans includes writing it on paper. Other forms of  data storage  are easier for automatic retrieval, but humans need a tool to read them.  Printing  a text stored in a computer allows keeping a copy on the computer and having also a copy that is human-readable without a tool.

4. Technology continues to provide and expand means for human beings to  represent , record and express their thoughts, feelings and experiences. Common and easy ways of recording information are by  sound  and by  video . A  report  or  account  is any informational work (usually of writing, speech, television, or film) made with the specific intention of relaying information or recounting certain events in a widely  presentable form . [1]

5. Recording/documentation and reporting is based on the philosophy that “what is not documented is not done”. Therefore to ensure continuity of management and providing adequate services and information for future agency’s policies; the concept of documentation and reporting cannot be overemphasized.

6. DEFINITIONS Recording or documentation is a set of data collected and received in a set of an organization which memorize and provide objective activities carried out and are compiled for reference and future use.

7. Report is a systematic way of presenting an account or any information to describe a set of action and analyzing certain events usually in writing, spoken on the media with the intension of relaying the information presented in tabular or narrative form and serves the purpose of making decision.

8. GENERAL PURPOSE OF RECORDING AND REPORTING Regulatory agencies require it (auditing) For research Serves as a legal document For statistic For education For reference For communication

9. PURPOSE OF RECORDING AND REPORTING IN RELATION TO NUR SING Regulatory agencies require it (auditing) For research Serves as a medico-legal document For statistic For education For reference

10. For patient and Nurses safety Ensures quality of care Medicare reimbursement depends upon it (planning)

11. PRINCIPLES OF RECORDING DATE AND TIME Document date and time of each recording Record time in conventional manner e.g. 9am, 6pm etc or according to the 24 hour clock Avoid recording in advance LEGIBILITY Entries must be legible and easy to read Writing must be clear Very important in recording numbers and medical terms

12. CORRECT SPELLING Correct spelling is essential for accuracy If unsure about the spelling, use the dictionary or other resource books PERMANENCE Entries should be done in dark ink. It helps to identify changes and allow duplication ACCEPTED TERMINOLOGY Use commonly accepted abbreviations, symbols and terms that are specified by the agency e.g *, ^, o, Use universally accepted abbreviations e.g SpO 2, CO 2

13. FACTUAL Descriptive objective information about what nurse sees hears feels and smells Use of inference without supporting data is not acceptable Vague terms like; appears, seems or apparently is not acceptable Include objective signs of problems Subjective data is documented in patient’s exact words within quotable marks

14. ACCURATE Use of exact measurement establishes accuracy. E.g. intake 450ml of water than writing adequate amount of water

15. Patient’s 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. If any mistakes occur while recording, draw a line through it and write error above or next to original entry with your initials or name. Do not erase, blot or use correction fluids Write out every line but not in between the lines

16. Draw a line through the blank spaces so that no additional information can be added SEQUENCE Document events in order of occurrence e.g. record pre-op assessment, intra-op activities and then the patient post-op order Update record as needed

17. APPROPRIATENESS Record information pertaining to the patient’s health problems and care only Avoid personal information that are inappropriate

18. COMPLETENESS Document all necessary information It should give a clear picture of what took place Complete pertinent assessment data such as vital signs, wound drainage, patient’s complaints, who was notified and what intervention was carried out etc and recorded CURRENT Timely entries are must Keeping record at bed side may facilitate immediate documentation

19. CONCISENESS (BREVITY) Recording need to be brief as well as complete to save time in communication Use accepted abbreviation ORGANIZED Information should have logical manner e.g. from pre-op care to intra- and post operative care. Easy to read SIGNATURE Each recording is signed by the recorder Signature includes the name and the title

20. PRINCIPLES OF REPORTING ACCURACY: Report factual information - Report information gained from the physical senses e.g. sight, smell, taste etc. or what was done and not what was merely imagined. Be aware of feelings that may destroy objective description. Strong feelings can cause the writer to seek evidence to support her feeling or reject evidence that does not support them. Make distinction between fact and hearsay, fact and opinion and facts and conclusion.

21. FACT AND HEARSAY A fact is information learned through the use of the investigator’s own senses or corroborated by information the investigator obtains. Statement from other persons even witnesses are hearsay Hearsay is generally admissible in administrative hearing and should not be ignored. Corroborate hearsay if possible FACT AND OPINION Fact has the quality of being independent and can be confirmed or substantiated. Opinion is an idea, an impression or a notion resulting from a personal sentiment Opinions are not a part of the main body of a report

22. FACTS AND CONCLUSION A fact proves itself while a conclusion requires collaborative evidence A fact exists independent of the observer while a conclusion exists only in the mind of the observer. A fact is observable, while a conclusion is reasoned A conclusion involves drawing an inference that looks like the logical consequence of preceding presuppositions, information or evidence COMPARABILITY This is done in a relative manner, by comparison to something else.

23. COMPLETENESS : A report should have every necessary or normal part or component or step No event should be omitted PURPOSEFUL A report should serve as or indicating the existence of a purpose Should have objective (aim or goal) RELIABILITY Should have the trait of being dependable i.e. worthy of reliance or trust. Provide a reliable source of information

24. REPETITION FOR CONFIRMATION The receiver repeats what the reporter said in order to confirm especially during a verbal report 

25. SUMMARY Historically, records of events have been for thousands of years in one form or another. Recording and reporting is a systematic way of documentation and accounting for a set of data collected based on the series of event that occur, carried out in accordance with the basic principles of recording and reporting It is done to ensure quality of care and good management as well as showing nursing actions, for research, policy making, safety of patients & the NURSES, and for medico-legal reasons.

26. CONCLUSION Recording and reporting are essential aspect of management of patients or in administration. Therefore, it should be systematic and based on the principles that ensure compliance with the regulatory agency’s policies. NURSES are duty bound to care and record and it is mandatory, so remember, what is not recorded is not done. Court believe more in what you’ve written than what you say

27. REFERENCES http://en.wikipedia.org/wiki/Recording , (2009), Retrieved March 5, 2015. http://en.wikipedia.org/wiki/Report , (2013), Retrieved March 5, 2015. Jijingi B., (2014), lecture note on principle of reporting & recording (unpublished) Mandyau (2014), lecture note on writing report (unpublished) Okeke A. (2014), lecture note on recovery room chart & anaesthesia record keeping (unpublished) www.trainingsevers.org/NARATN/attachment , (2005), Attachment 9 principle of good report writing.pdf, Retrieved Jan., 10, 2015.