Documentation and

reporting
By:
Sonam Maclay
Computerized documentation
• Nurses use computers to store the client’s
database, add new data, create and revise
care plans, and document client progress.
Computerized documentation-
advantages
– Increases the quality of documentation and save
time.
– Increases legibility and accuracy.
– Facilitates statistical analysis of data.
– The system links various sources of client
information.
Computerized documentation-
disadvantages
• Client’s privacy may be infringed on if security
measures are not used.
• Breakdowns make information temporarily
unavailable.
• The system is expensive.
• Extended training periods may be required
when a new or updated system is installed.
 Types of reports:
Reports commonly used by nurses include
• Hand off report
A.Change of shift report
B. Transfer report
• Telephone reports
• Incident reports
 Hand off reports
• Hand-off reports happen any time one health
care provider transfers care of a patient to
another health care provider.
• The hand off report may be change of shift
report or transfer report.
• The purpose of hand-off reports is to
provide better continuity and
individualized care for patients.
 Change-of-shift report
Change-of-shift report is given to all nurses on
the next shift
• It includes up-to date information about a
patient’s condition, required care,
treatments, medications, and any recent
or anticipated changes.
 Transfer report
Transfer report is given whenever the patient
is transferred to other health care unit.
It can happen between:
• Nursing unit-to-nursing unit transfer
• Nursing unit to diagnostic area.
• Special settings (operating room,
emergency department).
• Discharge and inter-facility transfer
• Hand off report can be given face-to-face, in
writing, or verbally such as over the telephone
or via audio recording
 Telephone Reports
• Health professionals frequently report about
a client by telephone.
• A registered nurse makes a telephone report
when significant events or changes in a
patient’s condition have occurred.
• Nurses inform primary care providers about
a change in a client’s condition; a
radiologist reports the results of an x-ray
study
• The nurse receiving a telephone report
should document the date and time, the
name of the person giving the information,
and the subject of the information received,
and sign the notation.

• For example 16/6/15 10.35 am Mr. Sahoo,

laboratory technician, reported by telephone
that Mrs. Anjali’s hemoglobin is 6 gm/dl. Sign
at the end
• The person receiving the information should repeat it
back to the sender to ensure accuracy.
• It is important that the nurse be concise and
accurate.
• Telephone reports usually include the client’s name and
medical diagnosis, changes in nursing assessment, vital
signs , significant laboratory data, and related nursing
interventions.
• The nurse should have the client’s chart ready to give
the primary care provider any further Information
• After reporting, the nurse should document the date,
time, and content of the call
 Incident or Occurrence Reports
• An incident or occurrence is any event that is not
consistent with the routine operation of a health care
unit or routine care of a patient.
• Examples of incidents include
• Patient falls,
• Needlestick injuries,
• A visitor having symptoms of illness,
• Medication administration errors,
• Accidental omission of ordered therapies, and
• Circumstances that lead to injury or a risk for patient
injury.
• Incident (or occurrence) reports are an important
part of the quality improvement program of a unit.
• Always contact the patient’s health care provider
whenever an incident happens
• In the incident report form document an objective
description of what happened, what you observed,
and the follow-up actions taken.
Minimizing the legal liability through
effective record keeping
 The patient’s record must provide an accurate, current, objective and
concise.
 Use a standardized form. This will help to ensure consistency and
improves the quality of written record. The nursing record should include
assessment, planning, implementation and evaluation of care
 Ensure the record begins with an identification details which includes the
personal data of the patient like full name, age, sex, hospital number etc.
 Ensure a supply of continuation sheet is available.
 Date and sign each entry, write full name. give the time using the 24hr
clock system e.g. write14:00 instead of 2pm.
 Write in dark ink, never in pencil and keep record out of direct sunlight.
This will help to ensure they do not fade and cannot be erased.
 On admission, record the patient’s blood pressure, pulse, temperature
and respiration as well s the result of any test.
 State the diagnosis clearly , as well as any problem the patient is currently
experiencing.
 Record all medication given to the patient and sign.
 Record all relevant observation in the patient’s nursing record as well as
on any other chart like TPR sheet, intake- output sheet, medication
record etc.
 Ensure that the consent form for the surgery or any procedure is clearly
signed by the patient
 Include a nursing checklist to ensure the patient is prepared for any
planned surgery.
 Ensure all plans made for the patient’s discharge e.g. whether they
understood details for follow up, competency to take medications.