Recording and reporting.pptx from nursing process

Recording and reporting from nurs

1. Recording and Reporting

2. A medical record is a collection of information about a person’s health, the care provided by health care providers, and the client’s progress. It is a health record or client record. Chart : is binder or folder that promotes the orderly collection, storage, and safekeeping of a person's medical records. All personnel involved in a client's health care contribute to the medical record by charting, recording, or documenting ( the process of entering information ). Uses for Medical Records Permanent Account: The record is filed and maintained for future reference. Sharing Information The documentation serves as a way to inform others about the client’s status and plan for care. Quality Assurance (an agency’s internal process for self- improvement to ensure that the level of care reflects or exceeds established standards) Accreditation Reimbursement --- Auditors ( inspectors who examine client records ) Education and Research Legal Evidence

3. Types of Client Records Source-oriented record (records organized according to the source of documented information). This type of record contains separate forms on which physicians, nurses, dietitians, physical therapists, and other health care providers make entries about their own specific activities in relation to the client’s care. Frequently, the fragmented documentation gives the impression that each health care provider is working independently of the others. Problem-Oriented Records Records organized according to the client’s health problems. They contain four major components: Common Components of a Problem Oriented Record Components Description 1. Data base Contains initial health information 2. Problem list Contains of a numeric list of the client's problems 3. Plan of care Identifies methods for solving each identified health problem 4. Progress notes Describes the client's responses to what has been done and revision to the initial plan

4. METHODS OF CHARTING Narrative charting (the style of documentation generally used in source-oriented records) involves writing information about the client and client care in chronologic order. SOAP charting (the documentation style more likely to be used in a problem- oriented record) (S = subjective data, O = objective data, A =analysis of the data, P = Plan for care) SOAP charting helps demonstrate interdisciplinary cooperation because everyone involved in the care of a client makes entries in the same location in the chart. Focus charting (a modified form of SOAP charting), which A focus can be the client’s current or changed behavior, significant events in the cli- ent’s care, or nursing diagnosis. PIE charting (a method of recording the client’s progress under the headings of problem, intervention, and evaluation) The PIE style prompts the nurse to address specific content in a charted progress note.

5. Charting by exception is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from a standard norm. Electronic charting (documenting client information via computer). Computerized electronic charting has many advantages: Consistent abbreviations - The information is always legible. Automatically records the date and time - Reduces medication errors Obtaining test results quickly - Omissions are fewer Computerized electronic charting has many disadvantages: Passwords must be changed regularly. - Electronic failures Information is scattered among various files. - Double charting Low level of Confidentiality - Expensive

6. Content of Nursing Documentation: Assessment data Client care needs Routine care such as hygiene measures Safety precautions Nursing interventions described in the care plan Medical treatments prescribed by the physician Outcomes of treatment and nursing interventions Client activity Medication administration Percentage of food consumed at each meal Visits or consults by health professionals Transportation to other departments Client teaching and discharge instructions Referrals to other health care agencies

7. Using Abbreviations: Abbreviations shorten the length of documentation and the time required for this task. Abbrev Meaning Abbrev Meaning Abd. Abdomen NSS Normal saline solution a.c. Before meals O2 Oxygen Ad lib As desired OB Obstetrics AMA Against medical advice OOB Out of bed Amt. Amount OR Operating room Approx Approximately Per By or through b.i.d. Twice a day P Pulse BM Bowel movement p.c. After meals B/P Blood pressure PO. By mouth bpm Beats per minute Postop. Postoperative c With Pre-op Preoperative C Centigrade Pt. Patient CCU Coronary care unit PT Physical therapy c/o Complains of q Every dc Discontinue qid Four times a day ED Emergency department     et And R/RT Right H2O Water R Respiration I&O Intake and output S Without IM Intramuscular stat Immediately IV Intravenous tid Three timed a day kg Kilogram TPR Temp,pulse, Respira L/LT Left UA Urinalysis L Liter via By way of lb Pound WC Wheelchair NKA No known allergies WNL Within normal limits NPO Nothing by mouth WT Weight

8. Indicating Documentation Time . The nurse identifies the date and time of each entry in the record. Traditional time: (time based on two 12-hour revolutions on a clock), which is identified with the hour and minute, followed by AM or PM. (example: 05:15am, 07:30 pm.). Military time: (time based on a 24-hour clock), which uses a different four-digit number for each hour and minute of the day . (example: 0515, 1440).

9. COMMUNICATION FOR CONTINUITY AND COLLABORATION Examples of written forms of communication include: Nursing care plan: is a written or printed list of the client’s problems, goals, and nursing orders for client care. It promotes the prevention, reduction, or resolution of health problems. Nursing Kardex: is a quick reference for current information about the client and care. The Kardex is not a part of the permanent record. Therefore, nurses can write information in pencil and erase. Checklist: is a form of documentation in which the nurse indicates the performance of routine care with a check mark or initials. It is an alternative to writing a narrative note. Flow sheet is a form of documentation with sections for recording frequently repeated assessment data.

10. Interpersonal Communication Communication takes place during personal interactions among health providers. Some examples are as follows: A change-of-shift report is a discussion between a nursing spokesperson from the shift that is ending and the arriving personnel. It includes a summary of each client’s condition and current status of care. Client care assignments: are made at the beginning of each shift. Assignments are posted, discussed with team members, or written on a worksheet. Team Conference: are commonly used to exchange information. Topics generally include client care problems, personnel conflicts, new equipment or treatment methods, and changes in policies or procedures. Rounds: (visits to the bedside of clients on an individual basis or as a group). When done as a group, the client is a witness to and often an active participant in the interaction. Telephone: Nurses use the telephone to exchange information when it is difficult for people to get together or when they must communicate information quickly.

11. Thank you