DOCUMENTATION

(RECORDING AND REPORTING)

BY: Adem Hussein (BSc, MSc)

Dec, 2022
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Documentation and charting

Documentation

Is defined as written evidence of interactions between and among

health professionals, clients, their families, and health care

organizations.

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Purpose
Documentation ensures:
Accurate data needed to plan the client’s care in order to
ensure the continuity of care
A method of communication b/n health care teams
Written evidence of performed activities for the client.
 Compliance with professional practice standards (e.g.,
American Nurses Association)
 A resource for review, audit, reimbursement, education,
and research
 A written legal record to protect the client, institution,
and practitioner
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 Charting

Charting is a written record of history,

examinations tests, diagnosis, prognosis, therapy
and response to therapy.

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Purpose

 For diagnosis or treatment of a patient while in the

hospital
 After discharge if patient returns for treatment at a
future time.
For maintaining accurate data on matters demand by
courts.
 For providing material for research.
 For serving as an information in the education of
health personnel
 For securing needed vital statistics
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 Orders of assembling patients chart
The order of assembling chart may differ from
hospital to hospital.
a. History sheet
b. Order sheet
c. Doctor’s progress notes
d. Nursing notes
e. Vital Sign Chart/graph
f. Laboratory reports(CBC, X-Ray, CT-Scan,
MRI-result…etc.)
g. Input and out put note
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 Equipment for charting and writing
notes:
Report format

Patient chart

Pen

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Caring for a patient during admission

Admission is the entry of a patient in to a

hospital ward for therapeutic or diagnostic
purpose.

Hospitalized individuals have many needs

and concerns that must be identified then
prioritized and for which action must be
taken.
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Purpose
 To help a new patient to adjust to hospital environment
and routines.

 To provide immediate care, safety and comfort.

 To observe sign and symptoms, and general conditions

of the patient.
 To enable the patient to use facilities, resource &
personal of the hospital.
 To alleviate fear, worry & loneliness about the hospital.
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 Types of admission
A. Emergency admission: are when patients are
admitted due to acute conditions requiring
immediate treatment.

B. Routine admission: admitted for investigation

and medical or surgical treatment given
accordingly.

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General instruction
1.Nurse should make every effort to be friendly and
well-mannered with the patient

2. Make proper observations or the patient’s condition.

3. Orient the patient and his relatives to hospital and

ward policies

4. Observe policies in dealing with medico-legal cases

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5. Deal with the patients belonging very carefully
communicable diseases

6. Isolate the patient if suffering from communicable disease

7. The nurse should be recognized the various needs of the

patient and meet them without delay

8. Understand the fears and anxiety of patient

9. Find out the likes and dislikes of the patient

10. Address the patient by their name and proper title.
11. Patient’s valuables and clothes should handover to the
relatives with proper recording
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 Transfer of the patient
• Transfer is shifting patient to another department
within the hospital or to another hospital/home.

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Purpose
1. To obtain necessary diagnostic tests and procedure
2. To provide treatment and nursing care
3. To provide specialized care
4. To place most appropriate utilization or available
personnel and services
5. To match intensity of nursing care, based on patients
level of needs and problems
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 Types of transfer of the patient
1. Internal transfer: to transfer the patient in
a unit that provide special care or care
suited to his need with in health facility,
e.g. from general ward to ICU
from operation room to wards
2. External transfer: to transfer the patient
from one hospital to another hospital for the
purpose of special care, e.g. from general
hospital to specialized hospital- cancer center
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 Preliminary assessment
A. Assess the method for transport, inform receiving
nurse,
B. Maintain patient’s physical wellbeing during transport
to new nursing unit
C. Provide verbal report about patient’ s condition to the
receiving unit nurse
D. Be sure all documentation including care plan is
completed
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 Preliminary assessment…….
E. Assist’s patients arrival to the new unit
F. Announce patients arrival to the new unit
G. Transport patient to the new room and
assist in transfer to bed
H. Hand over to receiving nurse

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 Patient Discharge
Discharge is sending the hospitalized patient
to home or to referral after successful
discharge planning process.

Patient discharge planning is a systematic

process for preparing the patient to leave the
hospital & for continuity of care at home.
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 Purpose
• To continue self care at home

• To adjust the patients setting out of the hospital

• To ensure adequate home health care support

• To minimize the patient’s anxiety at discharge

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 Indications for discharge

Good Progress in the patient's condition (cured)

No change in the patient's condition (Referral)

Against medical advice

Death

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 Procedure
1. Check for the doctor’s written order that pt.
to be discharged.

2. Inform patient and relative about discharge

3. Document relevant discharge information

4. Make sure all the fees are included

5. Send admission card to registration office

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 6. Plan for continuing care of the patient
Give information for a person involved in
the patient care.
Contact family or significant others, if
needed.
Facilitate transportation with responsible
unit

7. Assist patient to dress up

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 8. Teaching the patient about
• What to expect about disease outcome
• Medications (Treatments)
• Activity
• Diet
• Need for Follow up and others as needed

9. Do final assessment of physical and emotional

status of the patient and the ability to continue
own care.
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 10. Check and return all patients’ personal property
(bath items in patient unit and those kept in safe
area).

11. Help the patient or family to deal with business

office for customary financial matters and in
obtaining supplies.

12. Accompany patient to the gate, if possible

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 13. Write Discharge summaries note which usually
include:
Time and date of discharge
Description of client’s condition at discharge
Treatment (e.g. Wound care, Current medication)
Diet
Activity level
Restrictions
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Discharging a patient Against Medical Advice
(AMA)
When the patient want to leave an agency without
the permission of the physician –unauthorized
discharge the following activities are indicated:

1. Ascertain why the person wants to leave the agency

2. Notify the physician of the client’s decision

3. Offer the patient the appropriate form to complete

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 4. If the client refuses to sign the form, document the fact on
the form and have another health professional witness this

5. Provide the patient with the original of the signed form and
place a copy in the record

6. When the patient leaves the agency, notify the physician,

nurse in charge, and agency administration as appropriate

7. Assist the patient to leave as if this were a usual discharge

from the agency (the agency is still responsible while the
patient is on premises)

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 Critical incident reporting
Incident reports, or occurrence reports, are used
to document any unusual occurrence or accident
in the delivery of client care, such as falls or
medication errors.
Reporting is the verbal communication of data
regarding the client’s health status, needs,
treatments, outcomes, and responses.
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 When a report is given,
• It needs to summarize the current critical
information that facilitates clinical decision making
and continuity of care.

Nurses are required to file incident reports when

a situation arises that could or did cause client
harm.
When filing an incident report, the nurse should
state only the facts surrounding the incident.
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 Purpose:
 Informs the facility’s administration of the incident,
 Risk management personnel can consider changes
that might prevent similar occurrences in the future.
 Alerts the facility’s insurance company to a
potential claim and the need for further
investigation.
 Litigation can be avoided if the facility takes prompt
action by investigating an occurrence.
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 Key elements that must be addressed in
incident report
1. Record the date, exact time, and place you
discovered the occurrence.
2. Identify the person(s) involved in the occurrence,
including witness.
3. Document accurately and objectively the exact
occurrences that you witnessed or first saw after
the incident
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4. Record the exact details, in time sequence, what
happened, and the consequences for the persons

5. Record your actions to provide care and results of

your assessment for injuries or client complaints.

6. Notify the supervisor on duty and record the time

and name of the physician notified; if telephone orders
were received from the physician, document as
previously discussed and implement the orders.
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 7. Do not record your opinions, judgments,
conclusions, or assumptions about what occurred,
point blame, or suggest how to prevent
occurrence of a similar incident

8. Forward the incident report to the designated

person as defined in the facility’s policy.

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 Nursing progress note
The nurses’ progress notes are used to document the
client’s condition, problems, and complaints;
interventions; response to interventions; and achievement
of outcomes.

Progress notes is the evaluation of the client’s response to

treatment; may contain the progress recording of
interdisciplinary practitioners (e.g., dietary or social
services)
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Progress notes include the following forms:
• Nurses’ notes
• Medication administration record
• Personal care flow sheets
• Teaching records
• Intake and output forms
• Vital sign records and
• Specialty forms (e.g., diabetic flow sheet and
neurologic assessment form)
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 THE END

THANK YOU !!!

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