Documentation

Documentation
By / Mahmoud Shaqria
‫شقريه‬ ‫محمد‬ ‫محمود‬

Outline
1- Define nursing documentation.
2-purpose of nursing documentation.
3- Advantages of nursing documentation .
4- principles of nursing documentation .
5- Example of inaccurate & accurate nursing
documentation .

6- Define of Records & Reports
7- purpose of Records
8- principles of record writing
9-Types of records
10-Importance of records & reports
11-Criteria for Good Report
12-Types of reports

Nursing documentation
Any written or electronically generated information
about a client that describes the care or service provided
to the client .
Client refers to individuals , families , groups,
populations , or entire communities who require nursing
expertise .

Nursing documentation clearly describes :
1- Assessment of the client’s health
Status , nursing interventions carried out , and impact of
these interventions on client outcomes .
2- information reported to a physician or other health care
provider .

Purpose of nursing documentation
1- To facilitate communication .
2- To promote good nursing care .
3- To meet professional and legal standards

Advantages of nursing
documentation
Nursing documentation provides :
1- An account of judgment
2- critical thinking used in nursing process
3- Accurate, timely documentation reflects care provided :
Professional , legislative & agency standards
Enhance nursing care
Facilitate communication nurses & other health care providers

it also reflects the application of :
Nursing knowledge
Nursing skills & judgment
Established accountability
Conveys the unique contribution of the nursing to
health care .

Documentation principles
1- comprehensive & flexible
2- quality and continuity
3- track patient outcomes
4- reflect current standards
5- patient identification on every page of the record
6- Date , time and name

Example of inaccurate & accurate nursing
documentation
Inaccurate example ;
Mr. X received from morning staff in well condition .
Well oriented , eating well .
Vital signs checked the pt, no any further order .
Continue same RX .

Accurate example
Mr. X. received from Night shift . Oriented to time ,
place & person , Breathing spontaneously on room air ,
RR = 20/m. BP110/70 mmgh , pulse = 80/m. chest tube in
placed with bubbling & column movement present .
Catheter in placed urine output 30ml/hr stool passed
normally . Iv fluids 100ml /hr continue for 24hrs _______
A.Razzak

Records & Reports
The record and report system is a necessary activity in
every health care organization. It must be organized to
render service to the patients, medical staff, hospital
administration and society.
The kind and amount of service rendered in the hospital
will depend primarily on the accuracy of information
contained in patient records.

Importance of reports and records
1-Provide a mean of communication between the
physician and other professionals contributing to patient
care.
2. Furnish documentary evidence of the 'course of the
patient's illness and treatment during hospitalization.

3. Assist in protecting the legal interests of the patient,
hospital, physicians and nurses.
4. Serve as a basis of analysis, study and evaluation of
the quality of care rendered to the patient.
5. Provide clinical data for research and education.

6. Serve as a basis for planning individual patient care.
7. Provide continuity of patient, care on subsequent
admissions of the patient.
8. Provide data for insurance companies or pre-
payment agencies for compensation carriers
9. Provide information for medico-legal purposes and
for defenses in malpractice in hospital.

Records
Are administrative tools used to classify information and
prevent duplication of information, their usefulness
must be judged by the contribution they make to an
administrative educational or research objective.

Records ;
A record is a permanent written communication that
documents information relevant to a client’s health care
management.
A record is a clinical , scientific ,administrative and legal
document relating to nursing care given to the individual
family or community .

Purpose of Records
1- supply data that are essential for program planning and
evaluation.
2- provide the practitioner with data required for the
application of professional services for the improvement of
family & other development personnel
3- Tools of communication between health workers , the
family and other development personnel

4- Effective health records show the health problem in
the family and other factors that affect health.
5- indicates plans for future
6- help in research for improvement of nursing care

Principles of record writing
1- Nurses should develop their own method of
expression and form in record writing .
2- written clearly , appropriately and adequately .
3- contain facts based on observation , conversation and
action .
4- select relevant facts and the recording should be meat
, complete and uniform .

5- valuable legal documents and so it should be handled
carefully , and accounted for .
6- Records should be written immediately after an
interview .
7- Accurately dated , timed and signed
8- Records are confidential documents .

Importance of the record:
To inform the nursing staff in writing of the patient for whose
nursing care they are responsible and for any special
assignment.
- It is a tool for fixing responsibilities for nursing care.
- It is used for evaluating the nursing care given and for
discussion and conference

Records in common use by:
The nursing unit:
1. Patient records.
2. Assignment record.
3.Time record.
4. Census record
5. Narcotics and medication records

The nursing office
1. Master record of nursing hours.
2.Attendance record.
3. Personnel record.
a. Employment record,
b. Evaluation record

Nursing unit records:
1.Patient record:
It is an orderly written report of patient complaints. The
diagnostic findings, treatment and patient's progress that
in total contains sufficient information about the period of
hospitalization and the care given. This record should be
arranged in chronological order from the current data
back to the data of admission. It includes:

1.Admission and discharge records: is usually the top or
first form of medical record, the upper portion contains
information of an identifying nature, while the lower_
section contains a summary of the necessary discharge
data

2.History of physical examination: the primary purpose of a history and
physical examination is to assist the physician in establishing a diagnosis
on which to base the care and treatment of the patient.
3.Progress notes: should be specific statements relating to 'he course of
the disease, written and signed by the physician, internal or resident.
They should be written everyday, or even every few hours during the acute
phase of illness. All procedures performed should be recorded, dated and
signed in these notes.

4. Physician's orders: the written medical records
constitute the physician's directions to the nursing
and staff covering all medications and treatments given
to the patient.
5. Graphic record: which serves to give a graphic
picture of the temperature, pulse, respiration and blood
pressure. It provides space for recording intake and
output fluids

6.Vital signs record: is used to record frequent
observations such as temperature, and state of
consciousness. This is a special form used by nurses
in case of shock, hemorrhage, hyper or hypotension,
head injury, etc

7. Other records:
• Consultation report.
• Laboratory reports.
• Pathological report.
• Transfusion records.
• Anesthesia records

2. Assignment records:
Are records of the names of nursing personnel and the
patients assigned to their care. There is a special form to
be filled daily by the head nurse or the team leader for
each shift and should be located in place accessible to all
nursing personnel

The record should include:.
- Name of the head nurse (in charge nurse or team leader).
- Name and position of nursing personnel assigned during the shift.
- Name of the patient, diagnosis and nursing care needs or special
treatments, investigations to be done.
- List of special assignments.
- Time and place of conference or meeting.

3. Time record:
It is a weekly record, which indicates the planned
coverage of the nursing personnel for each nursing
unit. It should be made in duplicate, one copy is
retained in the unit and the other is sent to the nursing
office. The form should include:

- Name of all personnel on the unit including days off
and vacations and the various categories of personnel
being groups for a week or for 24 hours.
- In charge nurse's name at all times.
- Hours of conferences or meetings.

4. Census record:
It is a daily record for each unit from which the official
census of the hospital is derived. It could be filled by the
unit clerk and under the supervision of the head nurse.
The form includes:
- Number of beds in each unit.
- The census of the patients

5. Inventories record:
It is an itemized record for all articles of furniture, equipment and
instruments with identity date of quantity and all elements of the
articles. Inventory count ' should be made at periodic times as
hospital policy indicates.
There are certain items that need to be counted frequently, such as
instruments and syringes. Furniture and linen count is made
throughout the hospital at least once a year.

Nursing office records:
1. Master record of nursing hours:
This record is derived from the daily time records of the
nursing unit and should show the distribution of the
hours by each category or nursing personnel in the
hospital

2. Attendance record
3. Personnel record:
It is concerned with information about each individual nurse, assembled
in a file, which includes:
- Copied application.
- Photograph.
- Basic nursing education and professional preparation.
- Evaluation records

The personnel record consists of:
a. Employment record: includes:
- Position on employment.
- Professional preparation.
- Registration number.
- Date of employment.
- Date of promotion
- Insurance.

b. Evaluation record:
Is made periodically for all nursing personnel and indicates
the personal progress of the individual.
Importance:
- An objective basis on which to base personnel promotion.
- An incentive to individual progress.
- Provides reasons for poor performance, as well as
recommendations for work well done

Electronic record
Electronic health record :
Is collection of various medical records that get
generated during any clinical encounter or event.

Benefits of electronic medical
records
1- track data over time
2- identify patients who are due for preventive visits and
screenings.
3- Monitor how patient measures up to certain
parameters , such vaccinations and blood pressure
readings
4- improve overall quality of care in a practice

Reports
Reports are oral or written exchanges of information
shared between caregivers or workers in a number of
ways .
Reports is the summary of the services of person or
personnel and the agency

Types of reports
1. . Oral reports
b. Written reports:
1. Day, evening and night report.(shift)
2. Incident report.
3. Report of complaint.
4. Report including negligence.
5. Reports for requisition

A. Oral reports:
Are given when information is of immediate use and not
for permanency. They may be based on material
included in written reports, e.g. oral reports given by the
head nurse or the nurse in charge to all personnel (oral
shift report), reports on condition and needs of a patient
to the physician, supervisor, etc...

B. Written reports:
Are written summaries -conditions and activities related to
their care:
1. Day, evening and night report:
- Patient census
- All acutely ill and post-operative: patients. .
- Patients with any change in general condition, e.g. vital
signs or those who had special treatment.
- Admissions, discharges, transfers and deaths during
the shift.

2. Incident report
Any happening which is not consistent with routine operation of
the hospital or the routine care of a patient.
It may be an incident or a situation, which might result in an
accident, e.g. error in medication and omission of the treatment,
etc...
It is an important administrative tool for use in studying the cause
of accident or incidence in the hospital by providing information,
which will lead to effective preventive measures and in case of legal
actions.

form should include:
- Patient's name and diagnosis.
- Admission date.
- Time of incident or accident noted or reported.
- What was done.
- Date and signature of all individuals involved in the
incident and their professional status

3. Report of complaint:
Serious complaints, which cannot be handled by the
ward personnel, are reported to the nurse office. The
report should include:
- Statement of complaint.
- Justification as seen by the nurse.
- Measures taken to overcome the dissatisfaction.
- The result.
- Date and signature

4- census report
This is a report compiled daily for the number of patients .
Very
Often it is done at midnight and the norms are collected by
the night supervisor . The report will show the total number
of patients , the number of admissions , discharges ,
transfers , births and deaths .

Guideline for written reports
1- Include complete data, like : complete patient name
and hospital number on every sheet
2- Initiate each entry with data and time.
3- Chart after providing care, not before.
4- Chart as soon as posible.
5-Chart only your own observation , care, and teaching.

6- Be objective in charting.
7- Use only hard pointed, perminant black ink pens.
8- Be specific, accurate and complete.
9- Use concise phrase, begin each phrase with capital
letter and each new topic on a separate line.

10- Use only approved abbreviations and medical terms.
11- Use medical terminology only.
12-Follow rules of grammar and punctuation.
13-Fill all spaces. Draw a horizontal line in unused space.

14- Correct error in documentation as soon as possible.
15- Do not erase the error or use correction fluid.
16-Draw a single line through any erroneous information,
write the words, errors, or error in charting above it along
with your name and write the entry correctly

17- Put entries in order of consecutives shifts
and days.
18- Sign each block of charting or entry with
full name and title

Documentation

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