Recording and Reporting tools applied in the
clinical area
ETHICAL AND LEGAL CONSIDERATIONS: Protocol of
confidentiality in safekeeping and releasing of information
in the clinical area
• The American Nurses Association code of ethics
states that “… the nurse has a duty to maintain
confidentiality of all patient information”
• The client’s record is also protected legally as a
private record of the client’s care. Access to the
record is restricted to health professionals
involved in giving care to the client.
• The institution or agency is the rightful owner of
the client’s record. This does not, however,
exclude the client’s rights to the same records.
• For purposes of education and research, most
agencies allow student and graduate health
professionals access to client records.
• The records are used in client conferences, clinics,
rounds, client studies, and written papers.
RECORDING / DOCUMENTATION SYSTEMS
SOURCE-ORIENTED RECORD
• Traditional client record
• Each person or department makes notations in a
separate section or sections of the client’s chart.
PROBLEM-ORIENTED MEDICAL RECORD
• Established by Lawrence Weed
• The data are arranged according to the problems
the client has rather than the source of the
information.
POMR FOUR BASIC COMPONENTS:
1. DATABASE – consists of all information known
about the client when the client first enters the
health care agency.
2. PROBLEM LIST – is derived from the database. It is
usually kept at the front of the chart and serves as
an index to the numbered entries in the progress
notes.
3. PLAN OF CARE – Care plans are generated by the
individual who lists the problems.
4. PROGRESS NOTES – is a chart entry made by all
health professionals involved in a client’s care;
they all use the same type of sheet for notes.
PIE (Problems, Interventions, and Evaluation)
➢ groups information into three categories.
➢ This system consists of a client care assessment
flow sheet and progress notes.
➢ Eliminate the traditional care plan and incorporate
an ongoing care plan into the progress notes.
FOCUS CHARTING
➢ is intended to make the client and client concerns
and strengths the focus of care.
➢ Three columns for recording are usually used:
date and time, focus, and progress notes.
CHARTING BY EXCEPTION (CBE)
➢ is a documentation system in which only
abnormal or significant findings or exceptions to
norms are recorded.
Three key elements:
1. Flow sheets.
- GRAPHIC RECORD.
- INTAKE AND OUTPUT RECORD.
- MEDICATION ADMINISTRATION RECORD.
2. Standards of nursing care.
3. Bedside access to chart forms.
COMPUTERIZED DOCUMENTATION
• Electronic health records (EHRs) are used to
manage the huge volume of information required
in contemporary health care.
CASE MANAGEMENT
- Emphasizes quality, cost-effective care delivered
within an established length of stay.
• Nursing Care Plan (NCP)
• KARDEX
REPORTING
➢ The purpose of reporting is to communicate
specific information to a person or group of
people.
CHANGE-OF-SHIFT REPORTS
➢ “Handoff” communication
➢ is defined as a process in which information about
patient/client/resident care is communicated in a
consistent manner including an opportunity to ask
and respond to questions
TELEPHONE REPORTS
 ➢ Nurses inform primary care providers about a • Veracity – refers to telling the truth.
change in a client’s condition; a radiologist Members of the health team
reports the results of an x-ray study; a nurse may LEVEL 1 CHT members (Barangay Health Workers,
report to a nurse on another unit about a Barangay Nutrition Scholars, Traditional Birth Attendants,
transferred client. and others)
TELEPHONE ORDERS LEVEL 2 CHT leader (Midwife)
➢ Primary care providers often order a therapy (e.g., LEVEL 3 CHT supervisor (Rural health Physician, MHO/MO,
a medication) for a client by telephone. Public Health Nurses)
CARE PLAN CONFERENCE
➢ is a meeting of a group of nurses to discuss
possible solutions to certain problems of a client,
such as inability to cope with an event or lack of
progress toward goal attainment.
NURSING ROUNDS
➢ are procedures in which two or more nurses visit
selected clients at each client’s bedside.
Ethics and Morality: Professional ethics and standard of
nursing
Moral Development
➢ Is the process of learning to tell the difference
between right and wrong and of learning what
ought and ought not to be done.
Moral Frameworks
Consequence-Based (teleological) theories. Look to the
outcomes (consequences) of an action in judging whether
that action is right or wrong. One famous form is
Utilitarianism which judges consequences by a “greatest
good for the greatest number” standard.
Principles-Based (deontological) theories. The morality of
an action is determined not by its consequences but by
whether it is done according to an impartial, objective
principle.
Relationship-Based (caring) theories. Judges action
according to a perspective of caring and responsibility, it
promotes the common good or the welfare of the group.
Moral Principles
• Autonomy – refers to the right to make one’s own
decisions.
• Nonmaleficence – is the duty to “do no harm.”
• Beneficence – means “doing good.”
• Justice – is frequently referred to as fairness.
• Fidelity – means to be faithful to agreements and
promises.