Documenting and reporting Pages Prepared by: Dr.Reem A.Jarrad

Why communication between staff is important?  Because it enhances quality and continuity of clients care

Definitions of nursing communication methods  1- Discussion: is an informal oral consideration of a subject by two or more health professionals to identify a problem or to develop strategies to resolve one.

Definitions of nursing communication methods  2- Report: is oral, written or computer based communication intended to convey information to others.

Definitions of nursing communication methods  3- record : is a written or computer based documentation( charting or recording).

What are the purposes for using client records?  1- Communication  2- Planning client care  3- Auditing health agencies ( quality assurance)  4- Research  5- Education  6- Legal documentation  7-Health care analysis ( SWOT= strengths, weaknesses, opportunities, and threats)

Documentation Systems  1- Source oriented record  2- Problem oriented medical record  3- Pie ( problems, interventions and evaluation)  4- Focus Charting  5- Computerized documentation  Note : practice tips for documentation on the bottom of page 108).

General Guidelines for recording  1- Date and time  2- Frequency of documenting according to policy and client condition  3- Legibility ( easy to read..)  4- Permanence ( dark ink)  5- Accepted Terminology  6- Correct spelling

General Guidelines for recording  7- Signature  8- Accuracy ( how to manage wrong entry?)  9- Sequence ( order of occurrence )  10- Appropriateness ( relevant client data only )  11-Conciseness ( Brief recording )  12- Legal caution ( look nursing note page 107, right upper border, directly above word reporting )

Reporting  Definition:  to communicate specific information to a person or group of people, whether oral or written.

Examples for Reporting  1- Change of Shift Reports  2- Telephone reports  3- Care Plan Conference  4- Nursing Rounds  (Pages )

Good luck with first exam  - Which will be on the  The same time and place of the lecture.  - Two value- ethics lectures will remain after the exam, and will be included in the second exam Your Tutor