DOCUMENTATION &

REPORTING
 INTRODUCTION

 DOCUMENTATION: Documentation is the process of

communicating in written form about essential facts for the
maintenance of continuous history of events over a period of
time. Recording & reporting are the other ways of
documentation.
 RECORD: Record is a clinical, scientific, administrative legal
document relating to the nursing care given to individual, family
or community.
 Reports: Reports are oral or written exchange of information
shared between nurses/technicians or a number of persons.
PURPOSES OF DOCUMENTATION

LEGAL RECORD
COMMUNICATION

PURPOSES

EDUCATION
AUDIT

RESEARCH
 VALUES OR PURPOSES OF RECORDING

1. Record provide accurate and detail account of

treatment and care given to patient.
2. It provide guide for follow up of the course of disease
and further care.
3. Records has great value in the diagnosis, treatments
and nursing care.
4. A record saves the duplication of work & helps patient
to get prompt treatment.
5. A written record has legal value .
6. It safe guard the patient , nurse/technician and doctor
 VALUES OR PURPOSES OF RECORDING

5. Record furnish the vital statistics.

6. Data taken from patient problem points out the
health problem of country.
7. Helps to evaluate services provided. It provides
baseline data
 COMMUNICATION WITHIN HEALTH CARE TEAM

 In medical field communication with members of health team is very

important. It facilitates the process of patient care.
 IMPORTANCE OF COMMUNICATION WITHIN HEALTH TEAM
 As every member of health team gathers different information it helps in
planning comprehensive quality care of client.
 Sharing/communicating information helps to verify the cues thus reduces
ambiguity(Doubtfulness ).
 It also avoids duplication of efforts in collecting data.
 It helps the team members to benefit from the information others have
collected.
 Sharing the collected information keeps all the members in one direction
i.e. achievement of goal. It avoids deviation from achieving goal.
 Communication ensures coordination between health team members. In
order to provide quality care team efforts are required.
 TYPE OF RECORDS

 WARD RECORDS
 NURSE’S RECORDS
 STUDENTS RECORDS
 STAFF RECORDS
 ACADEMIC & ADMINISTRATIVE RECORDS.
 PATIENT RECORD

 Patient record in hospital is maintained as he /she comes to the

hospital for availing preventive & therapeutic services.
 OUT-PATIENT RECORD
 They provide information about out patient referral numbers, patients
biodata, medical history past & present, family history if any,
investigation records, diagnosis & treatment & frequency of visit.

 IN-PATIENT RECORD
 Admission record
 Observation record
 Investigation record
 Intake- output record
 Treatment record
 Diet record
 Progress record
 Nurse’s record
 Discharge record
all these records kept in one folder for each individual
patient in the ward under the charge of the ward sister till the patient is
discharged. Thereafter, it is transferred to the medical record section as
per rules.
 OTHER PATIENT RECORDS

 Other patient records maintained & kept in the nurses duty room
include treatment book, diet book, admission, discharge & death
register, notification form, inventories & related record forms, duty
roster etc.

NURSING SERVICE RECORD

These records are maintained by nursing service department. the
nursing service records include the nurses duty register, master plan of
nursing personnel, leave register which contains annual, casual, &
medical leave, nurses attendance register confidential records,
correspondence with other hospitals, agencies.
 NURSING EDUCATION RECORDS

 These records are maintained by principal’s office,school/college of

nursing, these record includes:
student admission record
attendance record
clinical master rotation plan
evaluation record
leave record
student health record
cumulative record
confidential record
 PRINCIPLES OF RECORD WRITING

 Clearly written & legible

 Accurate
 Appropriate
 Error-free
 Concise
 Complete
 Chronological order
 Specified date & time
 Use standard abbreviations
 Include all services & treatment given to patient with results
 Contd……

 Leave no blank space in between

 Signed by nurse/technician who enters the data
 Each page to have identification details, viz, name, age,
OPD No. etc.
 COMMON RECORD-KEEPING FORM

 A variety of forms are used to document client’s health status, problems,

interventions, response to interventions. These are the following:
 NURSING HISTORY: Nursing history is completed when client is
admitted to hospital. This form includes a complete assessment of client
to identify relevant nursing diagnosis. Information recorded on this form
provides a baseline data which can be compared with changes in client’s
condition.
 GRAPHIC SHEETS & FLOW SHEETS: Flow sheets have vertical &
horizontal columns for recording data, times to show assessment &
interventions. This help to identify changes in client’s condition. It is
used to document vital signs, IV therapy, routine repetitive care such as
meals, weight. It is very important to fill the flow sheets otherwise spaces
reflects no intervention carried out.
 NURSE’S PROGRESS NOTES: It includes client’s condition problems,
complaints, interventions & achievement of goal & outcomes. Progress
notes include following forms:
Nurse’s notes
Medication administration record
Personal care flow sheets
Teaching Records
Intake output form
Vital sign records
Diabetic flow sheet
Neurologic assessment
 Nurse’s progress notes can be completed in narrative form.
 Standardized Care Plan
 COMPUTERIZED DOCUMENTATION

 Health care system has directed to develop computerized records in

response to demand for clinical, administrative & regulatory
information. They use computerized system for supplies, equipment,
stock medications & diagnostic testing for sometime. Computers
facilitates:
 Speed in communication
 Accuracy in information
 Capability of information storage
 ADVANTAGES OF COMPUTERIZED DOCUMENTATION
 It enhances systematic approach to client care through standardize
protocols, teaching documents.
 It facilitates fast communication
 It is cost effective
 Increases quality of documentation
 Save documentation time by avoiding duplication of effort.
 DISADVANTAGES
 Costly installation of computer software
 Problem in protecting client’s confidentiality. As in hospital everyone
has access to computer recording.
 GUIDELINES FOR REPORTING

 Accurate: For hospital setting as well as research purposes, accuracy is very

important quality of documentation. Use medical terminology with correct
spellings in descriptive terms. Avoid using judgemental language such as
“good, poor, bad, seems". It is best to write client’s verbatum also. Avoid
using clues.e.g.INCORRECT:Client took one glass of
water.CORRECT:Client took 250 ml of water.
 Completeness: Always make complete sentences. Never leave space
inbetween lines. Even pictures can be drawn if needed at appropriate place.
Area of fractured bone. “Burn area” etc.Never forget to document the
information omitted or refused by the client. Avoid using local abbreviations
or symbols. Try to write full form of the word. For example ‘TOF’
“Tetrology of Fallot” TOF “Tracheoesophageal Fistula". Thus in this
example abbreviation TOF have two different diagnosis which can be
detected by fully written words.
 Currentness:Keep the documents upto date. If any change occurs in
hospital policies, timings, patient care etc. It must be written immediately.
 Organised:Start any entry with hospital name, Patient name, Gender,
Diagnosis, Date & Time. Write information in chronological order such as
assessment data, observation, intervention & evaluation. Recording
should be done as soon as the information is collected to avoid missing
data. It is not good practice to wait until the end of shift to record findings
of all clients.
 Confidentiality: This is very important to treat all client information in a
confidential & professional manner. It is an legal document & should be
available to the client’s health care team. It is nurse/technicians
responsibility to protect the privacy & confidentiality of client
interactions, assessment & care.
 Factual: A record contains descriptive & objective information about
what one gain through her senses. Document the findings with
supportive factual data. Avoid words such as “appears, seems,
properly". Documentation need to clearly explain the observations of
the client’s behaviors. It is also best to document the client’s “exact
words” within quotation marks.e.g. Client state “I feel very tensed &
feeling nothing is in my control". For objective data, nurse may check
client’s vital signs.
 METHODS OF REPORTING

Charting
Source Problem
Narrative PIE Focus By
Oriented Oriented
charting charting charting excep-
charting charting tion
 REPORTING

 Reporting is the verbal or written communication of data

regarding the client’s health status needs, treatments, outcomes &
responses. Reporting facilitates clinical decision making,
continuity of care & coordination among health team members.
TYPES OF
REPORTING

CHANGE OF TRANSFER
SHIFT REPORT INCIDENT
REPORT REPORT
 PURPOSES OF REPORTING

 Report is an essential tool of communication between the

patient, nurse & members of health team.
 It provides communication to the incoming
nurse/technician on duty by giving brief & accurate
information on the patient.
 It avoids duplication of work.
 Reports, when complete, helps provide better patient care.
 TYPES OF REPORTS

 Reports are classified as written & oral.

 WRITTEN REPORTS
 Reports among members of the nursing team, this is done
when the nurse leaves the ward off duty & gives the report to
the incoming duty nurse.
 Reports between the head nurse & staff nurse.
 Reports between the head nurse & nursing superintendent.
 REPORT TO THE PHYICIAN
The nurse has to report to the doctor about any
unusual conditions of the patient through incharge sister
 Contd……

 For instance, the patient may develop some reaction to

medicine, fall from the bed, missing from the ward. If
mistake is committed by the student nurse, report to the
doctor & matron immediately so that appropriate actions
can be taken.
 The past illness, reason for the patient transfer, his or her
condition to be noted & reported.
 Census report: it is the report of admissions, discharge,
death & transfer in 24 hrs done by he administrative office.
ORAL REPORTS
 It is given when the information is for immediate use & not for
permanency e.g. oral report is made but the nurse while assigning the
patients care to another nurse who is planning to relieve her. These
reports may be given by the bedside of each patient during taking over
& handing over rounds. While giving oral reports great care has to be
taken by the nurses. At the bedside of the patient, family history, name
& diagnosis can be explained. All other information can be relieved in
nurses duty room.
 contd…

 CHANGE OF SHIFT REPORT

At the end of each shift, nurses give information on their assigned
patients to the nurses working in the next shift. The report is a system
of communication aimed at transferring essential information
necessary for safe & complete care as per the nursing plan.
TELEPHONE REPORT
A nurse communicates information to a doctor about change in the
patients condition, to a nurse of another unit about a client transfer, or
the laboratory staff or radiologist regarding result of diagnostic test.
 TRANSFER REPORT
It involves communication of information on patients from the nurse
of the sending unit to the nurse of receiving unit. The receiving unit
must know the latest information on patients & their progress. This
report will also have the doctors transfer order.
INCIDENT REPORT
An incident is any event not consistent with the routine operation of a
health care unit. When the incident occurs, the nurse involved in it or
the nurse who witnesses it completes the incident report for the
departmental nurse Incharge & doctor.
 MINIMIZE LEGAL LIABILITIES

 In hospital setting, physicians, nurses are also involved in cases of

medical malpractice, negligence, personal injury. Now days public
is very much aware of their rights. Every client expects best quality
care in hospitals. Documents are the best black & white print
which reflect the care provided. Thus while documenting any
word, nurse should consider the possibility that client’s record may
be submitted to the court as a source of information regarding
client’s condition & nursing care. So in order to minimize legal
liabilities document should have following characteristics.
 Factual
 Accurate
 Complete
 Logically organized
 Client’s identifying information must be written on each page of the
client’s record. Nurse must ensure that she is writing notes on right
client’s record.
 While making entry on record it must be started with complete
date(month, time, year).
 Nurse should never edit or delete the documentation done by other
personnel
 At the end of nursing notes line can be drawn from end of text to end
of right margin on line so that no one else can add documentation.
 Documents must be signed by nurse/technician at the end of
entry
 Never leave empty space between entries as someone else can
add.
 While documenting follow the hospital policy.
 CARE OF RECORD

 Records kept under custody in a place which is not accessible to the

patient & his/ her relatives but accessible to doctors & nurses
 No stranger is allowed to read the record
 Records not to be handed over even to the legal advisor without the
written permission of the administrator.
 Records to be arranged in alphabetical, numerical, geographical orders
& with an index card .this records may be maintained by the record
room.
 See that the records of the patient is well maintained, complete &
signed by the doctor before sending to the record room, take the
signature of the person receiving the record & see that the patients
name, age, ward no, bed no, OPD no, diagnosis & treatment entered.
 Contd…..

 Patients record never sent out of the ward without doctors permission.
 If the patient is transferred to the another hospital, the nurse should
see that a complete summary is made in a separate paper to be sent
with the patient & not the original record.
 DO'S AND DON'TS OF NURSING
DOCUMENTATION

 Nurses are well aware of the standard, which states that if a certain
matter affecting patient care is required to be charted and it is not, the
overwhelming presumption is that it may not have been done. Good
documentation will help you to defend yourself in a malpractice
lawsuit, it can also keep you out of court in the first place.
 DO’S

 Check that you have the correct chart before you begin
writing.
 Make sure your documentation reflects the nursing process
and your professional capabilities.
 Write legibly.
 Chart the time you gave a medication, the administration
route, and the patient's response.
 Chart precautions or preventive measures used, such as bed
rails.
 Record each phone call to a physician, including the exact
time, message, and response.
 CONTINUED……

 Chart patient care at the time you provide it.

 If you remember an important point after you've completed
your documentation, chart the information with a notation
that it's a "late entry." Include the date and time of the late
entry.
 DON’T

• Don't chart a symptom, such as "c/o pain," without also

charting what you did about it.
• Don't alter a patient's record - this is a criminal offense.
• Don't use shorthand or abbreviations that aren't widely
accepted.
• Don't write imprecise descriptions, such as "bed soaked" or
"a large amount."
 CONTINUED……

• Don't chart what someone else said, heard, felt, or smelled

unless the information is critical. In that case, use
quotations and attribute the remarks appropriately.
• Don't chart care ahead of time - something may happen and
you may be unable to actually give the care you've charted.
Charting care that you haven't done is considered fraud