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- 1. Documentation and Reporting SONIA NOOR BSN(Gen.)
- 2. Documentation • Documentation is anything written or electronically generated that described the status of a client or the care or services given to that client. • Documentation serves as a permanent record of client information and care.
- 3. Purposes of documentation • Provides a written record of the history , treatment,care and response of the patient while under the care of a health care provider. • Is a guide for reimbursement of costs of care. • May serves as a evidence of care in a court of law. • Shows the use of the nursing process. • Provides data for quality assurance studies. • Is a legal record that can be used as a evidence of events that occurred or treatment given. • Shows progress towards expected outcomes.
- 4. Principles of documentation • Date and time • Legibility • Correct spelling • Permanence • Accurate • Sequence • Appropriateness • Completeness • Conciseness • Organized • Signature • Confidentiality
- 5. Record Definition • Record is a formally legal, administrative tool that permanently document information relevant to direct and indirect patient care. • Records are administrative devices used to collect and classified information.
- 6. Purposes of records • Supply data that are essential for programmed planning and evaluation. • Tools of communication between health workers , the family & other development personnel. • Effective health record show the health problem in the family and other factors that affect health. • Indicates plans for future. • Help in research for improvement of nursing care. • It provides baseline data to estimate the long-term changes related to the services.
- 7. Characteristics of good records and reporting • Accuracy • Conciseness • Thoroughness • Up to date • Organization • Confidentiality • Objectivity
- 8. Principles of record writing • Nurses should develop their own method of expression and form in record writing. • Written clearly, appropriately and adequately. • Contain facts based on observation , conversation and action. • Select relevant facts and the recording should be neat ,complete and uniform. • Record should be written immediately after an interview. • Records are confidential documents. • Accurately dated ,timed, and signed. • Not include abbreviations ,jargon ,meaningless phrases.
- 9. Importance of Records in Hospitals For the individual and family • Record serve to document the history of the client. • Record assist in the continuity of care. • Records serve as a evidence to support or to manage or to face the legal questions that arise. • Records serves to recognize the health needs and can be used as a research and teaching tool. For the doctor • Serves as a guide for diagnosis , treatment ,follow up and evaluation of services. • Indicates progress and continuity of care. • Help self evaluation of medical practice.
- 10. Continue… • Protect the doctor in case of legal issues. • Record may be used for teaching and research. For the nurse • Provide with documentation of services rendered , i.e. shows health condition of the client. • Provide data essential for planning and evaluation of services for further improvement. • Serve as a guide for professional growth. • Enable to judge the quality and quantity of work done. • Serves as a communication tool between staff and other members involved in care. • Indicate plans for future.
- 11. Types of Records • Patient clinical record • Individual staff record • Ward records • Administrative records with educational value.
- 12. Reports Definition • Reports are information about a patient either written or oral. (Sr. Nancy) • A report is a summary of activities or observation seen, performed or heard. (potter & Perry)
- 13. Purposes • Essential tool for communication. • To show the kind and amount of services rendered over a specified period. • To illustrate progress in teaching goals. • As an aid in studying health conditions. • As an aid in planning. • To interpret the services to the public and to the other interested agencies.
- 14. Types of Report • Oral report oral reports are given when the information is for immediate use and not for permanency. • Written Report written reports are to be written when the information to be used by several personnel which is more or less of permanent.
- 15. Types of Reports in Nursing Commonly used reporting in nursing. • Change of shift reports (CSR) • Transfer reports • Incident reports • Telephone reports
- 16. Change of shift reports • At the end of each shift nurses report information about their assigned clients to the nurses working on the next shift. • The report provides continuity of nursing care among nurses who are caring for a client. • Example: if first shift nurse find a certain pain relief measures effective for a client ,it is essential that the information be related to the next nurse caring for the client so that pain control intervention can be continued.
- 17. Transfer Reports • Patients are often transfer from one unit to another to receive different levels of care and treatment. EXAMPLE : client transfer from an ICU or critical care units to general nursing units when the client stable or no longer requires such intense monitoring.
- 18. When giving a transfer report , following information should be given:- • Pt name , age , primary physician and medical diagnosis. • Brief summary of progress up to the time of transfer. • Patient health status (physical & psychological). • Allergies (regarding drugs and medications). • Current treatment status(iv fluids or any type of transfusions). • Current nursing diagnosis or problem and care plan. • Patient current vital signs and current thermodynamic status(temp ., BP, PR,RR,Spo2,ECG etc.) • Any critical assessment or procedure performed before going to transfer a client. • Need for any special equipment (cardiac monitor,suction equipment).
- 19. Types of Incidents • Falling from bed or in toilet. • Needle stick injuries. • Burns(hot applications or from another sources ). • Drugs or medication administration errors. • Misidentification of patients. • Accidental omission of ordered therapies.
- 20. Incident Reports • An incident is any event that is not consistent with the routine operation of health care unit. • Incidents are commonly occur when patient under care within hospital settings. • Incident reports are in major part of a unit quality improvement program.
- 21. Guidelines to Report incident • Describe in concise what exactly happens especially in objective terms. • Enumerate incident unit , time etc. • Explain patient condition before and after incident. • Describe any treatment given after incident. • Record patient vital signs after incident. • No nurse should blamed in an incident report. • As soon as possible submit a report to the authority.
- 22. Telephone Reports • Nurse inform physician or other health care team members regarding changes in patient condition during caring and communicate information to nurses on other units about client’s transfer. • Telephone reports must contain clear , accurate and concise.
- 23. Common record keeping forms • Admission nursing history form • Flow sheets and graphic records • Patient care summary • Standardized care plan • Progress notes • Discharge summary forms
- 24. Methods of documentation/recording • Narrative charting • Source-0riented charting • Problem-oriented charting • PIE charting • Focus charting • Charting by exception • Computerized documentation • Case management with critical paths
- 25. Narrative Charting (traditional client record) • Describes the client’s status , interventions and treatments , response to treatments is in story format. • It is now replaced by other formats. Basic components of a traditional client record: • Admission sheet • Physician’s order sheet • Medical history • Nurse’s notes • Special record and reports (Xray , labs , refferals etc.)
- 26. Source-oriented charting • Each person or department makes notations in a separate sections of the client’s chart. • Narrative recording by each member of the health care team on separate records. • Most traditional • Different disciplines chart on separate forms • Each reader must consult various parts of the record to get a complete picture. • Record become bulky • For example the admission departments has an admission sheet,nurses use the nurses notes , physicians have a physician notes etc.
- 27. Problem-oriented Medical record(SOAP/IER format) uses a structured , logical foramt called S.O.A.P/I.E.R • S-subjective:what patient tells you.. • O-objective:what you observe,see. • A-assessment:what you think is going on based on your data. • P-plan:what you are going to do. • I-intervention:specific interventions implemented. • E-evaluation:patient response to interventions. • R-revision:change in treatment . • uses flow sheets to record routine care. • SOAP entires are usually made at least every 24 hours on any unresolved problem.
- 28. PIE Charting • P-problem statement • I-intervention • E-evaluation Example: • P: patient reports pain at surgical incision as 7/10 on 0 to 10 scale. • I:Given morphine 1mg iv at 10:35am. • E:patient reports pain 1/10 at 10:55 am.
- 30. Focus Charting • A method of identifying and organizing the narrative documentation of all client concerns. • Uses a columner format within the progress notes to distinguish the entry from other recordings in the narrative notes(date & time , focus , progress notes). • DATA-Sunjective or objective • ACTION-Nursing intervention • RESPONSE-Patient response to intervention • Example: D-Complaining of pain at incision site , pain scale;7/10 • A-repositioned for comfort.Demerol 50mg IM given • R-states a decrease in pain,”feels much better”
- 31. Charting by Exception(CBE) • The nurse documents only deviations from pre- established norms (document only abnormal or significant findings). • Avoid lengthy , repetitive notes.
- 32. Computerized documentation • Increase the qaulity of documentation and save time. • Increase legibility and accuracy. • Facillitates statistical analysis of data.
- 33. Case Management Process • A methodology for organizing client care through an ilness , using a critical pathway. • a critical pathway is a multidisciplinary plan or tool that specifies assessments , interventions , treatments and outcomes of health related problems a cross a time line.