Documentation and Reporting

Documentation refers to the process of creating written or electronic forms that provide
information about a patient's health history, assessment findings, interventions, and outcomes.
On the other hand, reporting involves relaying the information to other healthcare professionals,
such as physicians, other nurses, and family members. Documentation and reporting ensure the
continuity of care.

Why do we need to follow the practice guidelines in documentation?

We need to follow the practice guidelines in documentation to ensure accuracy in recording
patient information that is comprehensive and consistent. These guidelines ensure that the
documentation is complete and organized. By following the guidelines, it enhances
communication and collaboration among health care providers, which will minimize errors or
misunderstandings. Last but not least, provide high-quality patient care.

Date Time Notes

10/15/2023 9:00 am Patient reports sudden onset, severe headache upon
awakening. Headache is described as throbbing, located in
the frontal region. Pain rates as 8/10 on the pain rating
scale. The patient’s VS are stable Bp 120/80 mmHg, RR
16, Pulse 75 bpm. Associated symptoms include nausea.
10/25/23 10:00 am The patient received 500 mg of acetaminophen orally,
instructed to rest in quit, dark room.
10/25/23 10:40 am Patient’s headache has partially improved, now rated as
6/10. The patient’s nausea has also subsided.
10/25/23 11:45 The patient states he no longer feels headaches, no further
symptoms.
Narrative Charting

FDAR Charting
Time and Date Focus Data, Action, and Response
04/20/24 Patient has a fever Data: Patient is febrile, with a temperature above
normal range (39.4 ̊C
Action: Administered antipyretics and monitored fever
04/2024 Patient has a fever Response: rest in bed, fever subsided 37. 3̊C within 2
hours