Documentation And Reporting

By:Mr. M. Shivananda Reddy

• Documentation is anything written or printed on which you rely as record or proof of patient actions and activities.

• A record or chart or client record, is a formal, legal document that provides evidence of a client’s care and can be written or computer based.

• A report is oral, written, or computer-based communication intended to convey information to others.

• The process of making an entry on a client record is called recording, charting, or documenting

• Each health care organization has policies about recording and reporting client data, and each nurse is accountable for practicing according to these standards.

PURPOSE OF RECORDING AND REPORTING

Purposes:• The patient record is a valuable source of data for all

members of the health care team.• Client records are kept for a number of purposes

including:CommunicationPlanning client careAuditing health agenciesResearchEducationReimbursementLegal documentationHealth care analysis

Communication• The record serves as the vehicle by which different

health professionals who interact with a client communicate with each other.

• This prevents fragmentation, repetition, and delays in client care.

Planning Client Care• Each health professional uses data from the

client’s record to plan care for that client. • Nurses use baseline and ongoing data to evaluate

the effectiveness of the using care plan.• The physicians plans treatment after seeing the

laboratory reports of patient.

Auditing Health Agencies

• An audit is a review of client records for quality assurance purposes .

• Accrediting agencies such as The Joint Commission may review client records to determine if a particular health agency is meeting its stated standards.

Research• The information contained in a record can be a

valuable source of data for research. • The treatment plans for a number of clients with

the same health problems can yield information helpful in treating other clients.

Education

• Students in health disciplines often use client records as educational tools.

• A record can frequently provide a comprehensive view of the client, the illness and effective treatment strategies.

Reimbursement

• Documentation also helps a facility receive reimbursement from the government.

• For a patient to obtain payment through Medicare or insurance agencies the client’s clinical record must contain the correct diagnosis and reveal that the appropriate care has been given.

Legal Documentation

• The client’s record is a legal document and is usually admissible in court as evidence.

Health Care Analysis

• Information from records may assist health care planners to identify agency needs, such as over utilized and underutilized hospital services.

• Records can be used to establish the costs of various services and to identify those services that cost the agency money and those that generate revenue.

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 50 different professionals, including physicians, nurses, technicians, and others

• 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. Recording2. Reporting

All records contain the following information:• Patient identification and demographic data• Informed consent for treatment and procedures• Admission data• Nursing diagnoses or problems and nursing or interdisciplinary care plan• Record of nursing care treatment and evaluation• Medical history• Medical diagnoses• Therapeutic orders• Medical and health discipline progress notes• Physical assessment findings• Diagnostic study results• Patient education• Summary of operative procedures• Discharge plan and summary

• 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.

• 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.

GUIDELINES / PRINCIPLES OF RECORDING

Guidelines/ principles:

1. Factual2. Timing3. legibility4. Permanence5. Accepted terminology6. Correct signature7. Spelling

8. Accuracy9. Sequence10.Appropriate11.Complete12.Concise13.Legal prudence

• Factual• A factual record contains descriptive, objective information

about what a nurse sees, hears, feels, and smells.• Avoid vague terms such as appears, seems, or apparently

because these words suggest that you are stating an opinion, do not accurately communicate facts.

• Objective documentation includes observations of a patient’s behaviors.

• For example, instead of documenting “the patient seems anxious,” provide objective signs of anxiety and document “the patient’s pulse rate is elevated at 110 beats/min, respiratory rate is slightly labored at 22 breaths/min, and the patient reports increased restlessness.”

• The only subjective data included in the record are what the patient says.

• When recording subjective data, document the patient’s exact words within quotation marks whenever possible.

• Date and Time• Document the date and time of each recording. • This is essential not only for legal reasons but also

for client safety. • Record the time in the conventional manner (e.g.,

9:00 AM or 3:15 PM) or according to the 24-hour clock (military clock), which avoids confusion about whether a time was AM or PM

• Timing• Follow the agency’s policy about the frequency of

documenting, and adjust the frequency as a client’s condition indicates.

• for example, a client whose blood pressure is changing requires more frequent documentation than a client whose blood pressure is constant.

• As a rule, documenting should be done as soon as possible after an assessment or intervention.

• No recording should be done before providing nursing care

• Legibility• All entries must be legible and easy to read to

prevent interpretation errors. • Hand printing or easily understood

handwriting is usually permissible.

• Permanence• All entries on the client’s record are made in

dark ink so that the record is permanent and changes can be identified.

• Dark ink reproduces well in duplication processes.

• Follow the agency’s policies about the type of pen and ink used for recording.

• Accepted Terminology• People in the 21st century are often in a hurry and use

abbreviations when texting . • Even though using abbreviations is convenient, medical

abbreviations have been responsible for serious errors and deaths .

• Use only the standard and recognized abbreviations.• Ambiguity occurs when an abbreviation can stand for

more than one term leading to misinterpretation.• For example CP stand for chest pain, cerebral palsy, cleft

palate, creatine phosphate, and chickenpox

• Correct Spelling• Use correct spelling while documenting.• Correct spelling is essential for accuracy in

recording. Avoid spelling mistakes• If unsure how to spell a word, look it up in a

dictionary or other resource .• Two obsolutely different medications may have

similar spellings; for example, Fosamax and Flomax

• Signature• Each recording on the nursing notes is signed

by the nurse making it. • The signature includes the name and title; for

example, “M.S. REDDY, RN” • With computerized charting, each nurse has

his or her own password, which allows the documentation to be identified.

• Accuracy• The client’s name and identifying information

should be stamped or written on each page of the clinical record.

• Before making any entry, check that it is the correct chart.

• Do not identify charts by room number only; check the client’s name.

• Special care is needed when caring for clients with the same name.

• When a recording mistake is made, draw a single line through it to identify it as erroneous with your initials or name above or near the line (depending on agency policy).

• Do not erase, blot out, or use correction fluid. • The original entry must remain visible.• When using computerized charting, the nurse

needs to be aware of the agency’s policy and process for correcting documentation mistakes.

• Write on every line but never between lines. If a blank appears in a notation, draw a line through the blank space so that no additional information can be recorded at any other time or by any other person, and sign the notation

• Sequence• Document events in the order in which they

occur; • for example, record assessments, then the

nursing interventions, and then the client’s responses.

• Appropriateness• Record only information that pertains to the

client’s health problems and care. • Any other personal information that the client

conveys is inappropriate for the record. • Recording irrelevant information may be

considered an invasion of the client’s privacy .

• Completeness• Not all data that a nurse obtains about a client can be

recorded.• However, the information that is recorded needs to be

complete and helpful to the client and health care professionals.

• Nurses’ notes need to reflect the nursing process. • Record all assessments, dependent and independent nursing

interventions, client problems, client comments and responses to interventions and tests, progress toward goals, and communication with other members of the health team.

• Conciseness• Recordings need to be brief as well as

complete to save time in communication. • Repeated usage of the client’s name and the

word client are omitted.

• Legal Prudence• Accurate, complete documentation should give

legal protection to the nurse, the client’s other caregivers, the health care facility, and the client.

• Admissible in court as a legal document, the clinical record provides proof of the quality of care given to a client.

• For the best legal protection, the nurse should not only adhere to professional standards of nursing care but also follow agency policy and procedures for intervention and documentation in all situations—especially high-risk situations.