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Documentation and Reporting in Nursing

By: Bryan Mae H. DegorioDocumentation

- is defined as anything written or printed that is relied on as record or proof for authorized persons

- effective documentation reflects the quality care and provide evidence for healthcare members accountability in giving care Medical Record or Chart

- is an account of the clients health history, current health status, treatment and progress

- is a highly confidential legal documents by which nurses, physicians, and other team members communicate about the clientMultidisciplinary Communication Within HealthcareReports- includes both the oral and written exchange of informations between caregivers intended to convey information to other.Consultations- is a form of discussion whereby one professional caregiver gives formal advise about the care of a client to another caregiverDiscussion- is an informal oral consideration of a subject by two or more healthcare providers to identify problem or established strategies to resolve a problem Purposes of Documentation:CommunicationPlanning patients careLegal documents- the clients record is legal document and is admissible to court.- CARE NOT DOCUMENTED IS CARE NOT DONE- Common Problem in Documentationa. Not charting the correct time when evens occurredb. Failing to records verbal orders or failing to them signedc. Charting actions in advance to save timed. Documenting incorrect dataResearchEducationQuality assurance monitoring/Auditing monitoringStatisticsReimbursementFinancial BillingTypes of RecordsTemporary records- these are temporary records use to facilitate communication to maintain information for easy accessibility- must be updated whenever there is a change in the patients plan of careex. - vital signs list- white board notation- bedside turning records- medication card

Permanent records- it can be paper chart or a computerized recorda. paper chart- a permanent record of the clients healthcareb. Computerized record- it allows to quickly enter specific assessment data and information and retrieval of dataSystem of Organizing Contents:

Source-oriented Records (SOR)- the client chart is organized so that each discipline has a separate part in which to record the data- components:a. Admission sheetb. Physician order sheetc. Medical Historyd. Nurses notese. Special records or reportsProblem Oriented Clinical Records (POCR-POR)- the data about the client is recorded and arranged according to the problem the client has rather than according to the source of informations- Components:1. database- contains all the available assessment information pertaining to the client- it is subjected for revision 2. Problem list- is a list of problem that is carefully compiled once the database had been collected and analyzed - each problem is labelled and numbered so that it can be identified throughout the records- it can be active or inactive- when several problems have common etiology 2 methods are being used:

a. Sub-listing- is a group of all manifestations of a major problem that requires separate managementex. I- Vehicular accidentIA- Self-care deficitIB- Impaired mobilityIC- Total Incontinence

b. Cross-referencing method- lists all problems separately using consecutive number- a Related to on the rightex.

c. Redefinition- is necessary to reflect a change in the client problemProblem listRelated toCVA2. Self-care deficit#13. Impaired Physical Mobility#1Initial list of orders or Nursing Care Plan- is generated by the person who list the problem- Medical Care plan Nursing Care PlanProgress Notes- healthcare team monitor and record the progress of a clients problem- ways of writing progress notes:a. SOAP/SAPIE/SOAPIERb. PIE formatc. Focus Chartingd. Charting by ExceptionsSOAP/SOAPIE/ SOAPIERS- Subjective- consists of all the informations obtained from the clientO- Objective- consist of information that are obtained and measured by the sensesA- Assessment- is the interpretation or conclusion drawn form the subjective and objective data- is the statement of the clients problemP- Plan- is a plan of care designed to resolve the problem I- Implementation- specific interventions actually been performed by the caregiverE- Evaluation- clients response to the nursing and medical interventions R- Revisions- reflects care plan modification suggested by the evaluation

PIE format- it groups information into 3 Categories- P- refers to the specific problems using NANDA - if no approved diagnosis- utilize the HRA format I- Interventions- employed to manage the problem E- Evaluation- is the effectiveness of the interventions

Focus Charting- is intended the client and the client concerns to be the focused of care - Format:D- data (both subjective and objective data)- reflects the assessment phase of the nursing process and consists of observation of client status and behaviour including the data from the flow sheet A- Action (Nursing Interventions)- reflects planning and implementation and includes immediate and future nursing action

R- Response- reflects the evaluation phase of the nursing process and describe the client response to nay nursing or medical interventions

4. Charting by Exception- is a short hand method for documenting normal findings and routine care based clearly defined standards of practice and pre-determined criteria for nursing assessment and interventions - the nurse write progress notes only when the standardized statements on the form is not met- Components:a. Unique flow sheet with pre-determined assessment parameters and findingsb. Documentation by reference to the standards of nursing practicec. Bedside accessibility of documentation form Common Record Keeping Forms

Nursing Health History- it is completed during the admission of the client- it provide baseline data that can be compared with changes in the client conditionNursing Kardex- is a from or card that is kept in a potable flip-over file or notebook at the nurse station - it as a tool for the change-of-shift report-data available in the Kardexa. Personal datae. Daily nsg proceduresb. Basic needsf. Medication IVc. allergiesg. tttd. Dx testGraphic sheets and flow sheets- these are forms that allow nurses to assess the client and document routine repetitive care quickly- it includes: graphic sheets, I and O sheet, medication and daily nursing careNursing Care Plan- 2 types:a. Traditional care planb. Standardized care plan

Discharge and Summary Forms- it contains information with emphasis on preparing the client for efficient, timely discharge from a healthcare institution - discharge summary includes:a. Description of the clients condition upon dischargeb. Current health medicationc. treatmentd. diete. Activity levelf. Restrictions

Discharge Against Medical Advice/ HAMA or AMA - these are use by the agency to those client who leave the institution without the permission of the physician

Characteristics of Good Recording

TimingConfidentialityPermanence- all entries in the chart are made in dark colored ink so that the record is permanent and changes can be identifiedSignature- each recording on the nursing notes is signed by the nurse making it.- include the NAME and the TITLE- affix the signature and place at the end of the charting at the right margin of the nurses notesAccuracy- accurate notations consist of facts or exact observation rather than opinions of an observation ex:

- place client complaint in quotation- ERROR in charting- if BLANKS APPEARS IN NOTATION

CorrectWrongAte 50% of food servedAte with fair appetiteIntake of 360 mlDrank an adequate amount of fluidRefused medicationUncooperativeSequence and Organizing- document event in the order in which it occurs and notes should appear in each succeeding line.- avoid DOUBLE CHARTING- avoid squeezing informations into a space in betweenAppropriateness- only information that pertains to the client health problem and care is recordedCompleteness- the information that is recorded needs to be complete and helpful to the client and health care provider- the following informations should be charted:a. Physicians visitb. Times the patient leaves and return to the unit and mode of transportation and destinationc. Medication should be charted immediately after givend. Treatment should be charted immediately after givenUse of standard terminologyBrevity- entries are concise- start with capital and end with a periodLegal Awareness- chart only what you have personally have done, observed, heard, smelled and feltDo not use the word Pt in the chart

Types of Reporting

Change-of-sift report/Endorsement- is an oral report given 2-3 times a day by the nurses to all nurses on the next shift- purpose: continuity of care- bases: healthcare needs- ways of reporting:a. Face to faceb. Audiotape recordingc. Walking endorsementTelephone Reports- use to inform physician of changes in clients condition, transfer to another unit and relay lab result- should provide clear, accurate and concise information- document the following in telephone orders:a. When the call was madeb. Who made the callc. Who was calledd. To whom the information was givene. What information was givenf. What information was received

Telephone Orders- is usually given during night and emergency situation only- guidelines for T.O.a. Repeat the prescribed order back to the physicianb. Write the T. O. including the date, time given, name of the client, nurse and physician and the complete orderc. Allow the physician to sign the order within 24 hours

Transfer report- done when transferring client from one unit another- it should include the following:a. Clients name, age, primary physician and medical diagnosisb. Summary of the progress up to the time of transferc. Current health statusd. Current plan of caree. Any critical assessment or interventions to be completed shortly after transferd. Any special consideratione. Needs for equipment