1. Documentation and Reporting
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Documentation and Reporting
Concepts of Nursing-NUR 123

2. Documentation as Communication
Reporting and recording are the major communication techniques used by health care providers.
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3. Documentation as Communication
Documentation is defined as written evidence of:
The interactions between and among health professionals, clients, their families, and health care organizations.
The administration of tests, procedures, treatments, and client education.
The results or client’s response to these diagnostic tests and interventions.
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4. Purposes of Health Care Documentation
Professional Responsibility and Accountability
Communication
Education
Research
Legal and Practice Standards
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5. Legal and Practice Standards
Informed consent means that the client understands the reasons and risks of the proposed intervention.
Witnessing confirms that the person who signs the consent is competent.
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6. Elements of Effective Documentation
Use of Common Vocabulary
Legibility
Abbreviations and Symbols
Organization
Accuracy
Documenting a Medication Error
Confidentiality
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7. Elements of Effective Documentation
Use of Common Vocabulary
Improves communication and lessens the chance of misunderstanding between members of the health team.
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8. Elements of Effective Documentation
Legibility
Print if necessary.
Do not erase or obliterate writing.
State the reason for the error.
Sign and date the correction.
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9. Elements of Effective Documentation
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Correcting a documentation error

10. Elements of Effective Documentation
Abbreviations and Symbols
Always refer to the facility’s approved listing.
Avoid abbreviations that can be misunderstood.
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11. Elements of Effective Documentation
Organization
Start every entry with the date and time.
Chart in chronological order.
Chart medications immediately after administration.
Sign your name after each entry.
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12. Elements of Effective Documentation
Accuracy
Use descriptive terms to chart exactly what was observed or done.
Use correct spelling and grammar.
Write complete sentences.
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13. Elements of Effective Documentation
Documenting a Medication Error
Document in the nurses’ progress notes:
Name and dosage of the medication
Name of the practitioner who was notified of the error
Time of the notification
Nursing interventions or medical treatment
Client’s response to treatment
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14. Elements of Effective Documentation
Confidentiality
The nurse is responsible for protecting the privacy and confidentiality of client interactions, assessments, and care.
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15. Methods of Documentation
Narrative Charting
Source-Oriented Charting
Problem-Oriented Charting
PIE Charting
Focus Charting
Charting by Exception (CBE)
Computerized Documentation
Case Management with Critical Paths
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16. Methods of Documentation
Narrative Charting
Describes the client’s status, interventions and treatments; response to treatments is in story format.
Narrative charting is now being replaced by other formats.
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17. Methods of Documentation
Source-Oriented Charting
Narrative recording by each member (source) of the health care team on separate records.
For example the admission department has an admission sheet, nurses use the nurses’ notes, physicians have a physician notes, etc….
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18. Methods of Documentation
Problem-Oriented Charting
Uses a structured, logical format called S.O.A.P.
S: subjective data
O: objective data
A: assessment (conclusion stated in a form of nursing diagnoses or client problems)
P: plan
Uses flow sheets to record routine care.
SOAP entries are usually made at least every 24 hours on any unresolved problem.
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19. Methods of Documentation
PIE Charting
P: Problem statement
I: Intervention
E: Evaluation
Example:
P: Patient reports pain at surgical incision as 7/10 on 0 to 10 scale
I : Given morphine 1mg IV at 2335.
E : Patient reports pain as 1/10 at 2355.
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20. Methods of Documentation
Focus Charting
A method of identifying and organizing the narrative documentation of all client concerns.
Uses a columnar format within the progress notes to distinguish the entry from other recordings in the narrative notes (Date & Time, Focus, Progress note)
The progress notes are organized into: Data (D), Action (A), Response (R).
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21. Example of focus charting
Date & Time Focus: Progress notes:
05.Jan Acute pain related to surgical incision D: Patient reports pain as 7/10 on 0 to 10 scale A: Given morphine 1mg IV at R: Patient reports pain as 1/10 at 2355.
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22. Methods of Documentation
Charting by Exception (CBE)
The nurse documents only deviations from pre-established norms (document only abnormal or significant findings).
Avoids lengthy, repetitive notes.
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23. Methods of Documentation
Computerized Documentation
Increases the quality of documentation and save time.
Increases legibility and accuracy.
Facilitates statistical analysis of data.
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24. Methods of Documentation
Case Management Process
A methodology for organizing client care through an illness, using a critical pathway.
A critical pathway is a multidisciplinary plan or tool that specifies assessments, interventions, treatments and outcomes of health related problems a cross a time line.
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25. Forms for Recording Data
Kardex
Flow Sheets
Nurses’ Progress Notes
Discharge Summary
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26. Forms for Recording Data
The Kardex is used as a reference throughout the shift and during change-of-shift reports.
Client data (e.g name, age, admission date, allergy)
Medical diagnoses and nursing diagnoses
Medical orders, list of medications
Activities, diagnostic tests, or specific data on the pt.
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27. Forms for Recording Data
Flow Sheets
The information on flow sheets can be formatted to meet the specific needs of the client.
(e.g.: graphic sheets for vital signs, intake & output record, MAR, skin assessment record).
Nurses’ Progress Notes
Used to document the client’s condition, problems and complaints, interventions, responses, achievement of outcomes.
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28. Forms for Recording Data
Discharge Summary
Client’s status at admission and discharge.
Brief summary of client’s care.
Interventions and education outcomes.
Resolved problems and continuing need.
Referrals.
Client instructions.
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29. Concepts of Nursing-NUR 123
Reporting
Verbal communication of data regarding the client’s health status, needs, treatments, outcomes, and responses
Reporting is based on the nursing process.
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30. Concepts of Nursing-NUR 123
Reporting
Summary Reports
Walking Rounds
Incident Reports
Telephone Reports and Orders
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31. Reporting Summary Reports Walking Rounds Incident Reports
Commonly occur at change of shift (or when client is transferred).
Walking Rounds
Occur in the client’s room
Include Nursing, physician, interdisciplinary team.
Incident Reports
Used to document any unusual occurrence or accident in the delivery of client care.

32. Concepts of Nursing-NUR 123
Reporting
Telephone Reports and Orders
Report transfers, communicate referrals, obtain client data, solve problems, inform a physician and/or client’s family members regarding a change in the client’s condition.
Telephone orders are documented in the nurses’ progress notes and the physician order sheet.
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33. Documenting a Telephone Order
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.