Adebanjo kehinde 21/0630

Ajuonwu somtochukwu Franklin 22/1328

Olayiwola aduragbemi 21/0736

Ajaegbu Chigozirim Remnant 22/0713

AJawuihe Chelsea Chidinma 21/2358

Egwakhe Jc 22/2118

Oroge Sinmileoluwa Dominion 22/1374

Bakare Wuraola 20/1337

Iyiola Eniolaoluwa Esther 22/0438

WHAT IS REPORTING, RECORDING AND DOCUMENTING IN THE

GENERAL SENSE?
Reporting, recording, and documenting are all important processes in various aspects of
life. Whether it's in school, work, or even personal matters.
These practices involve gathering and organizing information to create a record or
document for future reference or analysis.
Reporting typically involves conveying information about an event, situation, or
progress to someone else. It can be done verbally or in writing, depending on the
context. For example, in a work setting, you might need to report on the progress of a
project to your boss or team members.
Recording refers to the act of documenting information or data for future reference. This
can include taking notes during a meeting, keeping a log of activities, or maintaining
records of financial transactions.
Documenting involves creating a more formal and comprehensive record of information.
These practices are essential for maintaining accurate records, facilitating
communication, and ensuring that important information is properly documented.

WHAT IS RECORDING IN CONTEXT TO NURSING?

Recording involves taking note of all the essential information about a patient's care,
including:
 ● Assessments,
● Treatments,
● Medications,
● And any significant observations.

This meticulous activity serves as a vital historical record of the patient's care, ensuring
continuity, accuracy, and accountability.

HOW IS RECORDING DONE?

To make a good record the following must be done:
1. It should be written immediately after an interview.
2. A nurse should develop their own form of record writing and method of
expression(still containing the essentials) e.g. date of birth, basic information and
the head to toe vital signs result).
3. It must be accurately dated and timed.
4. Avoid abbreviations and meaningless phases.
5. Select the relevant facts and avoid cancellations.
6. It should contain facts based on observations.

Importance of recording

1. Continuity of Care: It ensures that all healthcare providers have access to

accurate and up-to-date information about the patient's care, promoting
seamless continuity.

Legal Documentation: It serves as a legal record of the patient's care, providing

crucial evidence in case of disputes or legal matters.

1. Communication: It facilitates effective

communication among healthcare team members, ensuring that everyone is on the
same page regarding the patient's condition and treatment.

2. Accountability: Accurate recording holds healthcare professionals accountable

for their actions and decisions, promoting transparency and trust.

3. Quality of Care: It supports the delivery of high-quality care by providing a

comprehensive overview of the patient's health status and treatment history.

4. Monitoring Progress: Recording allows for the tracking of patient progress,

enabling healthcare providers to assess the effectiveness of treatments and
interventions.

5. Research and Analysis: It provides valuable data for research and analysis,
contributing to the advancement of medical knowledge and practices.
6. Legal Compliance: Proper recording ensures compliance with legal and
regulatory requirements, safeguarding both the patient and the healthcare institution.

7. Risk Management: It helps identify potential risks and complications, allowing

for proactive measures to mitigate them and enhance patient safety.

8. Resource Allocation: Accurate recording assists in the efficient allocation of

resources, ensuring that the patient receives the appropriate care and support.

9. Education and Training: It serves as a valuable educational resource for

healthcare professionals, offering real-life case studies for learning and training
purposes.

10. Patient Engagement: Recording can involve the

 patient in their own care by providing them with insights into their treatment and progress,
fostering engagement and empowerment.

11. Decision-Making: It provides essential information for healthcare professionals

to make informed decisions about the patient's care and treatment plans.

12. Performance Evaluation: It supports performance evaluation and quality

improvement initiatives by providing data for assessment and analysis.

13. Continual Improvement: Recording allows for continual improvement in healthcare

practices by identifying areas for enhancement and innovation.

WHAT IS REPORTING IN CONTEXT OF NURSING?

Reporting involves communicating relevant information about a patient's condition to other

members of the healthcare team.

This can be done verbally during shift handovers or through written reports. It ensures that
everyone involved in the patient's care is aware of important details and can make informed
decisions.

HOW TO WRITE A GOOD REPORT:

There are criteria’s to follow in order to make a good report and they include:

1. Reports should be made promptly in order to serve their purpose well.

2. It must be clear, complete and concise
3. It is to be clearly stated and well organized for easy understanding
4. Oral reports should be clearly expressed and presented in an interesting manner and
only important points should be emphasized.
When it comes to making a good report in nursing, there are a few important things to
consider:

First, organize your report in a clear and structured manner.

● Start with the patient's basic information.
● Followed by their medical history, current condition.
● And any significant changes. Include vital signs, medications, and any interventions
or treatments provided.
● Be concise and use appropriate medical terminology.

Lastly, communicate any concerns or important updates to the receiving nurse.

IMPORTANCE OF REPORTING

● Lets you know how to treat the patient

Let’s take the example of nursing report writing. How would you know anything about a
patient when you start your shift without having any knowledge about it? Without a nursing
report, you can not know anything about the patient. A nursing report can help the nurse
know how to take care of that particular patient. You can not treat all patients the same.
Everyone has a different issue and if you try to solve it without enough information, it might
be dangerous for the patient. When a nurse hands over a nursing report to the other nurse, all
the information is passed on to the hands of the other nurse which makes it easy for her to
take care of the patient.

● Improves patient’s safety:

According to studies, filling out nursing reports makes the report look secure. The first ones
to take care of the patient are the nurses and the nursing report is an integral part of their care
plan. A nurse is accountable to communicate with the other nurse about the report before
changing their shift to ensure the safety of the patient. The main issues the nurse verifies are;

● Health history
● Plan of care
● Physical assessment
 ● Decrease the anxiety of the patient’s family:
A patient’s family often thinks too much about their health. To help them get to know about
all the information of the patient, a nursing report writing example is a great way to decrease
their anxiety level. By getting to know about all the medical status of the patient, they can be
sure of what the real problem is.

WHAT IS DOCUMENTING IN NURSING?

Documenting in nursing refers to the process of creating a written record of a patient's care,
including their medical history, symptoms, diagnosis, treatment plan, and any other relevant
information. It's an essential part of providing high-quality patient care and ensuring that the
patient's needs are met.

THERE ARE TWO MAIN DIFFERENT TYPE OF DOCUMENTING:

● Subjective documentation
● Objective documentation.

Subjective documentation: Refers to the nurse's observations and impressions of the patient,
such as their mood, demeanor, or overall well-being.
Objective documentation: On the other hand, refers to factual information about the patient,
such as their medical history, symptoms, and lab results.
Both types of documentation are important, but objective documentation is more objective
and less prone to bias or misinterpretation.

HOW TO MAKE A GOOD DOCUMENTATION

According to the American nursing association certain principles can aid good documenting.
They include:
1. Understanding documenting characteristics: One should make sure that their
documentation is accessible, relevant, consistent, clear, sequential, timely and
reflective of the nursing process.
 2. Education and training: in order to have proper documentation there should be a
comprehensive guide and training on how document work.
3. Policies and procedures: the nurse should be familiar with organizational policies
and procedures related to documentation and apply these as part of nursing practice.
4. There should be protection systems designed and built into documentation systems
paper based or electronic in order to provide the following as prescribed by industry
standards and organizational policies and procedures. e.g protection of patient’s
identity.

IMPORTANCE OF DOCUMENTING IN NURSING

● First, it ensures that there is a complete and accurate record of the patient's care. This
is crucial for continuity of care, as other healthcare providers can access the patient's
records and make informed decisions about their treatment.

● It's important for legal reasons, as documenting can help protect the nurse and the
patient in the event of a lawsuit or other legal action.

● Documentation can also be used for research and quality improvement purposes, so
that the healthcare system can constantly improve and provide the best possible care
for patients.

In as much as documenting is important there are several ethical considerations to keep in

mind while documenting which are:

● First, confidentiality is of the utmost importance, and any information about the
patient must be kept private and secure.

● Additionally, the nurse must be honest and accurate in their documentation, without
omitting or fabricating any details.

● Finally, the nurse must consider the potential impact of their documentation on the
patient's care and well-being, and avoid any bias or discrimination.
These ethical considerations are essential for maintaining trust and ensuring high-quality
patient care.
Another thing to consider when it comes to documentation is legibility. It's important for
nurses to use clear, concise language that is easy to read and understand, both for themselves
and for other healthcare providers.
Documentation should be free of abbreviations, acronyms, or jargon that could be confusing.
Additionally, it's important to use correct spelling and grammar, so that the meaning of the
documentation is not lost.

What Is An Ethical Dilemma In Nursing? An ethical dilemma in nursing is a situation where

a nurse must decide between competing values and know that no matter what choice they
make, there are consequences.
The ethical dilemma in recording, reporting, and documenting in nursing practice revolves
around balancing patient confidentiality with the duty to provide accurate and thorough
information for effective patient care.
Here nurses must navigate the fine line between safeguarding sensitive information and
ensuring that crucial details are communicated to the healthcare team. Striking this balance
requires adherence to ethical principles, privacy laws, and maintaining trust with patients
while upholding the standard of care.
Additionally, nurses may face dilemmas when documenting errors or suboptimal care, as
honesty may conflict with concerns about professional consequences.
Another ethical consideration in nursing documentation involves the potential for bias or
subjective interpretation. Nurses must be aware of their own perspectives and strive to
present information objectively. This becomes especially challenging in situations where
personal judgments may influence the tone or content of the documentation. Maintaining
impartiality is crucial to ensure fair treatment and to avoid perpetuating stereotypes or biases
that might impact patient care.
Ethical nursing documentation calls for a commitment to accuracy, objectivity, and cultural
sensitivity in conveying patient information.
Nurses must navigate these complexities to uphold the highest standards of ethical practice,
ensuring that patient information is documented conscientiously to support optimal healthcare
outcomes.
Differences between recording, reporting and documenting
The criteria for differentiating the following:
Time frame, Formality and purpose. Which is represented by the table below.

CRITERIA RECORDING REPORTING DOCUMENTING

Time frame Recording happens reporting usually Documenting is

happens after the taken after the event
almost immediately
event and is done and can be stored to
or shortly after an over a period of be referred to later
time. on.
event and is kept till
needed.

Formality Recordings do not Reports can be Documents are

have to be written formal as they formal as they are
formally as they can require the required to be
be written in a raw information to be structured and may
and unstructured structured and have formalized
format. systematically standards.
arranged so the
information being
presented could be
understood.

purpose. Recordings are used reports are used to Documents are

to capture and store present recorded data stored information
data and and information. used to refer back to
information. recorded data and
events.

Now we know about recording, reporting, documentation, their importance, differences and
dilemmas you can face as a nurse.

With this information we the Group 22 members have given you, we hope that you
understand why you, being a nurse, should take them seriously in order to give the best care
to your patient.

Thank you