Documentation and reporting

Introduction :---
Documentation is a communication tool for
exchange of information stored in records
between nurses and other care givers.
 Documentation
1. Documentation is a way of communicating information regarding
patient pertaining to the assessment, diagnosis, planning,
implementing and evaluation of care and treatment in written form.
2. It gives an idea of what, when, where and how an event occurred.
3. It serves as legal document.
4. It may be handwritten or computerized.
5. It acts as a source, for communicating observations, decisions, actions
and response of client to those actions among the members of
healthcare team.
6. It can be relieved on as a record of proof for authorized persons.
7. Recording and reporting are two ways of communication.
• Definition :---
 Documentation in nursing practice is anything written or electronically
generated that describes the status of client on the care or services
given to that client.
 Nursing documentation refers to written or electronically generated
client information obtained through nursing process.
 Purposes of documentation in nursing
practice
1. To facilitate communication:-- nurse communicate to other nurses and
care providers, about the status of the patient, nursing interventions that
are carried out and the results of these interventions through accurate
documentation. This decrease the potential for miscommunication of
errors.
2. To promote good nursing care:-- encourage nurses to assess patient’s
progress and to determine which interventions are effective, identify and
document the changes to the plan of care as needed.
3. To promote nursing research:-- it facilitates nursing research, all of which
have the potential to improve the quality of nursing practice and patient
care through documentation.
4. To meet the professional and legal standards:-- * documentation in
nursing is a valuable and important method for demonstrating that within
the nurse-patient relationship the nurse has applied nursing knowledge,
skills and their judgement according to professional standards. * the nurses
documentation may be used as proof or evidence in legal proceeding such
as lawsuits and disciplinary hearings through professional regulatory
bodies.
Guidelines for effective documentation in
nursing practice
• Good documentation has six characteristics:--
1. Factual:- descriptive objective information about what the nurse sees, hears, feels, smells
and thinks. Subjective data is documented in client’s exact words within quotation marks.
2. Accurate:-use of exact measurement establishes accuracy. For example,” intake of 400ml of
water” than writing “ adequate amount of water”.
3. Complete-be sure to include:-
 Patient’s responses especially unusual, undesired or ineffective response.
 Communication with the patient’s family
 Entries in all spaces on all relevant assessment forms. Use N/A or other designation as per
policy for items that do not apply to your patient.
 Do not leave any entry blank.
4. Timely( date and time):-
 Document date and time of each recording.
 Record time in conventional manner (e.g. 9:00 am to 6:00 pm or according to the 24 hours
clock).
 Avoid recording in advance (this practice is illegal falsification of the records which
contribute to errors and confusion and threatens patient safety).
 Patient’s name, the word can be emitted.
5. Concise:- recording needs to be brief as well as complete to save time and communication.
6. Legible:- use black/blue pen (as per hospital protocol). Writing should be clear.
in case any mistake occurs while recording, draw a line through it and write
above or next to original entry with your initial or name.
 Records and Reports
• Definition of record:--
 A record is a permanent written communication that documents
information relevant to a client’s healthcare management.
 A record is a clinical, scientific, administrative and legal
document relating to the nursing care given to the individual
family or community.
• Definition of report:--
 Reports are oral or written exchanges of information shared
between caregivers or workers in a number of ways.
 A report is the summary of the services of person or personal
and of the agency.
 Purposes of records and reports
1. Way of communication:- records are way of communication between
members of healthcare team regarding treatment, care, procedures carried
out, client’s needs and progress. The notes that has been put up in records
should be written in clear and concise manner so that it can be easily
understood and errors can be omitted. Records promote the continuity of care.
2. Planning patient care:- records are the source of information that are used by
all the healthcare members since the admission of the patient till the time of
discharge. With the help of records, day-by-day progress of patient can be
assessed, which further guides the healthcare member to plan treatment and
care.
3. Quality improvement and audit:- audit is the method to assess the quality of
the care and treatment provided. Reviewing a client’s record is done in audit. It
is done to keep a check that the care provided to patient is meeting the
standard and quality of care according to institution or not. It also helps in
establishing quality improvement programs and continuous nursing education.
4. Reimbursement:- records contain information regarding diagnosis, treatment,
medication and care provided to the client during hospitalization, which is
important to receive the payment from the government or insurance
companies.
4. Research:- the information in client’s records serve as an important source of data for
retrospective as well as prospective research studies. All the data giving information
about occurrence of a particular disease, its complications, causes and risk factors,
treatment and medical and nursing therapies carried out, response of various patients
to various therapies and deaths occurring due to disease can be gathered from patient’s
records for research purpose. It also help nurses to discover a new nursing intervention.
5. Education:- records function as a great educational tool for medical and nursing
students. Students can use the information in records for case study. it dispenses the
detail about the assessment, diagnosis, signs, symptoms, treatment, therapies, care and
nursing intervention carried out, which help the student to learn and expand their body
knowledge. It also help the student to relate theoretical knowledge with practical
knowledge.
6. Legal documentation:- records serve as legal document that contain diagnosis,
treatment and medication information of the client. It protects patient’s right to be
informed.
7. Quality of care:- needs and goals of the patient can be identified through records. The
care plan and response of the client to that care and nursing interventions and day-by-
day progress lend a hand appraise the quality of care.
8. Decision analysis:- information contained in records helps the hospital administration in
analysing their decision time to time to do strategic planning regarding needs of the
client.
9. Vital statics:- according to UNO, “ vital statics is the numerical description of the birth,
death, abortion, marriage, divorce, adoption, and judicial description.”
10. Health service planning: records are beneficial in finding out the health problems,
people are suffering from.
Types of client records
• Ward records:-
1. Patient clinical record:- it includes in patient as well as outdoor patient records. In
patient clinical records contain all the details of the patient’s demo-biographical data,
which is fill on the first visit to a hospital. It can be filled at OPD also.
2. Doctor’s prescription sheet:- it is the written prescription sheet where doctor mentions
all the treatment to be started and if any modification are done that also is mentioned.
3. Lab investigation:- these are color coded slips for different laboratory investigations,
they are sent to the lab with samples and report is charted in these investigations
forms.
4. Consent form:- this is the form used for taking the consent of the patient for any
therapeutic or diagnostic procedure.
5. Diet sheet:- this is the sheet which is used for prescription of the diet and daily dietary
requirement is charted. For example, salt restricted diet for hypertensive patient.
6. Intake output:- it is used to record the intake ( whatever patient has eaten or any
intravenous fluids/ nasogastric feed given) and output (urine, stool, vomit, or drainage).
7. Reports of physiotherapy:- this is related to additional therapies provided like
physiotherapy visit and exercises done and their effect, or occupational therapy etc. in
this sheet relevant information is recorded by the health team member.
8. Death register:- it keeps the record of the patients who are died in the ward during
their stay in the hospital. Everything including what, when, why, how it occurred and
what action was taken is mentioned in the register.
8. Instruction book:- it is the book used to record any special instructions related to the patient,
e.g., if patient complains of abdominal pain and doctor prescribe that patient shall be prepared
for surgery- this instruction will be mentioned or recorded in the instruction book.
9. Census book:- this the record of total number of admission, discharge, transfer in and transfer
out or absconding patient or any deaths in the area or ward.
10. Admission and discharge book:- this the record of the patient where details (demographic
profile) at the time of admission or discharge is recorded. It provided record of total number of
admission and discharge per day.
11. Call book:- this is the book where name of the doctor, date, time and purpose of the call is
written and sent to the doctor, which is needed for patient consultation. It was used earlier
when page and mobile phones or on call system was not in practice, now it is written for record
purpose.
12. Complaint book:- this is used for any repairs needed in the area like maintenance of electricity
and water supply.
13. Movement register:- it provides the information related to the healthcare team members
movement, like on duty any one has one work, which needed to be done, then in the
movement book entry is made and time, purpose and place (going where is written) and on
return time is entered. It is a legal document.
14. Indent book:- this is the book used to order supplies from the stores like medicines, linen or
any other supply used for patient care.
15. Drug maintenance book:- this is the record book kept for the supply and demand of the drugs
used in area.
16. Crash cart register:- it is used to keep the record of all the drugs and equipment in crash cart.
• Nursing record:- nurses are responsible for maintaining and filling patient records. Nursing
records are maintained following the nursing process. Various nursing records are as
follow:-
1. Nursing assessment records:- this record is used to keep the data obtained after taking
history and performing physical assessment. This data serves as a baseline to keep a
check on client’s progress.
2. Care plan:- care plan are basically the outline of the nursing care provided and nursing
interventions implemented on the client in an attempt to improve the client’s condition
and to fulfill the identified goals and needs of the client.
3. Progress notes:- these notes give an idea to all the members of the healthcare team
about how much progress have been made by the client.
4. Kardexes:- the kardex is a widely used, concise method of organizing and recording data
about a client, making information quickly accessible to all health professionals. The
system consists of series of cards kept in a portable index file or on a computer generated
forms. The information on kardex may be organized into sections. example.,
 Pertinent information about client, such as name, room, age, religion, martial status,
admission date, diagnosis, etc.
 List of medications with date of order and time of administration of each.
 List of IV fluids with the date of infusion
 List of daily treatment and procedures ordered such as X-ray or lab results.
 A problem list stating goals, and list of approaches to meet the goals and relieve the
problems.
• Whether kardex is a written paper or computerized, it is important to have a place on it to
record date and initials of the person revising.
6. Flow sheets:- a flow sheet enables nurses to record nursing data quickly and concisely and
provides an easy to read record of the client’s condition over time.
7. Vital signs sheet:- the record of temperature, pulse, respiration and blood pressure is made
and the same values are represented graphically so that even any slight deviation from
normal values can be noted quickly.
8. Medication record:- this includes the details of all the medicines administrated to the client
along with dose, route, time and the signature of the nurse administrated the medicines.
9. Intake and output record:- also known as fluid balance chart. This is the record of
measurement of the patient’s fluid intake orally, through feeding tubes and output in the
form of urine, vomit and drain per day.
10. Discharge and transfer summary:- discharge note or transfer not put by the nurse when the
patient is discharged and transferred. It summarizes all the information of client, which
includes its diagnosis, findings of physical examination, treatment and care provided,
procedures performed till date and condition of the client at the time of discharge and
transfer.
• Educational records:-These are records used by teaching nursing institutes, it includes
teaching component like course plans, master rotation and clinical rotations of student as well
as staff members, minutes of committee meeting, students health records and cumulative
records, annual records, written policies and staff development program details.
• Administrative records:-These records are maintained by top level management like
philosophy, policies, vision and mission of institute or the details of staff and their job
descriptions etc. it includes records of treatment, admissions, equipment losses and
replacements, personnel performance and other administrative records.
 Electronic health records
• Definition:-
• An electronic health records is defined as a collection of various medical records that get
generated during any clinical encounter or events. - Vikaspedia
• Benefits of electronic health records:-
1. It ensures that patient records can be easily accessible from anywhere and at any
time.
2. It can be stored easily, in less space and for an indefinite time.
3. Being in electronic format, it reduces the number of records lost.
4. Improve the quality of patient records and are cost-effective.
5. Help to track patient’s clinical progress and improve patient confidence.
6. Gives a summary report of the various clinical encounters in a person’s lifetime.
7. It helps to improve the accuracy and speed of diagnosis, and avoid repeating
unnecessary tests.
8. It can be transferred easily within and across healthcare facilities.
9. Easy to update and can be made available to be used by multiply users at single point
of time.
10. Allow keeping backup of patient records at a very low cost.
11. Facilitate improved healthcare decisions and provide evidence-based care.
12. It can be used for research purposes.
 Computerized documentation
• Nowadays computers has great role in hospital. In nursing it can be divided into 3
categories:-
1. Clinical system:- in clinical system data about patient can be entered. Computer can sort
and analysis data. Facilitate computer among healthcare team members.
2. Management information system:- it can used for patient classification, suplies and
material management, staff schedule policies, procedure changes, budget information
and personal record, stastical reports.
3. Education system:- it can be used for giving instructions to the students computer based
records i.e., the electronic medical reports are used in any health care setting to
facilitate the delivery of client care and support the data analyses necessary for strategic
planning.
• Advantages:-
1. Eligibility of information.
2. Increase time efficiency, consituency and agoracy in the report keeping.
3. Provide data based for research.
4. It links varies resources.
5. Client information, request and results are send and receive quickly.
6. Computer records can facilitate a focus on client outcome.
7. It is possible to transfer information enter into the system to the outer area.
• Disadvantages:-
1. Client may not have privacy if security measures are not used.
2. System failure can cause unability of source information.
 Principles/guidelines for
documentation/reporting
Methods and system of documentation/
recording
• Narrative documentation:-
• It is the traditional method for recording nursing care. It is simply the use of a story
like format to document information specific to client’s condition and nursing care.
Narrative charting, has many disadvantages, including the tendency to have
repetitious information, to be time consuming, and to require the sort through much
information to locate desired data.
• Problem oriented medical record:-
• It is a method of documentation that places emphasis on client’s problems. The
POMR has four basic components:-
1. Data base:- it consists of all information known about the client when the client
first enters the healthcare agency. It includes the nursing assessment, physician’s
history, social and family data, and the results of the physical examination and
baseline diagnostic tests.
2. Problem list:- this list is derived from data base. It is usually kept at the front of the
chart and serves as an indx to the numbered enteries in the progress notes.
Problems are listed in order to identified, and list is continually updated as new
problems are identified and others are resolves. Physicians write problems as
medical diagnosis, surgical procedures. Nurses write problems as nursing diagnosis.
3. Plane of care:- it is made with reference to the active problems. Care plans are
generated by person who list the problem.
4. Progress notes:- it is chart entry made by all health professional involved in client
care. They all use same types of sheet for notes. Progress notes are numbered to
correspond to the problems on the problem list and may be lettered for the type of
data. Example, SOAP
• S- SUBJECTIVE DATA consists of information obtained from what client says. It describes the
client’s perceptions of and experience with the problem.
• O- OBJECTIVE DATA consists of information that is measured or observed by use of
senses{ e.g., vital signs, lab and X-ray results}.
• A- ASSESSMENT is the conclusion drawn about subjective and objective data. During initial
assessment, the problem list is created from database. The A entry should be a statement of
the problem.
• P- PLANNING is the plan of care designed to resolve the stated problem. The initial problem
is written by person who enters the problem into the record.
• Problems, interventions and evaluation {PIE}:-
• This sytem consists of a client care assessment flow sheet and progress notes. The flow
sheet uses specific assessment criteria in a particular format, such as human needs. The PIE
notes are numbered according to client’s problems.
• Focus charting:-
• It involves use of DAR notes which include:-
• D- data
• A- actions or nursing intervention
• R- response of client
• Focus charting is easily understood by caregivers and adaptable to most healthcare settings.
• Charting by exception:-
• This system of healthcare recording assessment, interventions and responses was developed
to eliminate redundancy and to organize information in a manner that would reduce error in
documnetation when used following a through orientation to the guidelines and protocols
establish for nursing assessment and intervention.
• CBE can:-
1. Save time
2. Reduce repetition of documentation
3. Provide immediate identification of significant changes in a client
condition.
• Key elements required for CBE are:-
1. Practice setting documentation and policies.
2. Assessment norms
3. Standards of cares
4. Unique flow sheets
5. Bed side assessibility of documentation norms.
• Case management:- the case management model of delivering care
incorporates a multidisciplinary approach to documenting client
care. In many organizations the standardized plan of care is
summarized into critical pathways for a specific disease or condition.
The critical pathways are multidisciplinary care plans include client
problems, key interventions and expected outcomes within an
established time frame.
 Reports
• reports are oral, written or audio, tape or exchange of information between
care givers. Reports given by nurse include change of shift reports, telephone
reports, transfer report. A physician calls a nursing unit to receive a verbal
report on a client condition. The laboratory submits are written reports
providing the diagnostic test.
• Purpose of reports:-
1. To show the kind and quality of services provided to the patient.
2. To shaow the progress of the patient and outcome of treatment and care
provided.
3. Aids in studying health conditions.
4. Helps in planning further plan of care.
• Types of reports:-
1. Oral report:- it is sometime used as an emergency and followed by a written
report letter and oral report is made by the nurse who is assign to patient
care to another nurse who is suppose to relief her.
2. Written report:- it should concentrate on the past anad present and future
states of patient or event.
3. 24 hours report:- nursing supervisior and nursing administrative need to be
kept informed of what is happening in all patient care areas.
4. Census report:- the daily census or the number of patient’s are admitted the
hospital this report help in planning of health care services and knows about
the morbidity and motality statistics.
5. Accidental report:- writing a detail report on mistake or accident that has taken
place oin the care of patient’s. it should be promtly inform to the higher
authority by writing accidental report.
6. Change of shift report:- at the end of each shift nurses record information about
their assigned clients to the nurses working on the next shift.
7. Transfer report:- it involve communication of information about clients from the
nurse or sending to the nurse on the receiving unit.
8. Other report:- it include report among member of the nursing team. Reports
between the3 head nurse and her assistant. Reports between the head nurse
and nursing supertendent.
• nurses responsibilty for record keeping and reporting
1. The patient has a right to inspect and copy the record after being discharged.
2. Medical record must be accurate to provide a sound basis for care planning.
3. Errors in nursing charting must be corrected that leaves no doubts.
4. In reporting information about criminal acts obtained during patient care,
rthe nurse must reveal such information only to the police, because it is
considered as a privileged communication.
5. A record about client contain descriptive, objective information about what a
nurse sees, heatrs, feels and smells.
6. A client record must be reliable. Information must be accurate so
that health team members have confidence it.
7. Delays in recording or reporting can result in serious omissions and
untimely delays dor medical care or actions legally; a late entry in
a chart may be interpreted as negligence.
NURSING INFORMATICS:-
“ application of computer technology to all fields of nursing – nursing
services, nurse education and nursing research.”
- Scholes and barber
• Purposes of nursing informatics:
1. To support the use of the nursing process.
2. The use of a computer – based scheduling package to allocate
staff in a hospital or healthcare organization.
3. The use of the computer for patient education
4. The use of computer – assisted learning in nursing education
5. Nursing use of a hospital information system; ort research related
to information nurses use in making patient care decisions and
how those decisions are made.