1. Chapter 26 Accountability: Documentation and Reporting
Fundamentals of Nursing: Standards & Practices, 2E
Chapter 26
Accountability:
Documentation and Reporting

2. Documentation as Communication
Communication is a dynamic, continuous, and multidimensional process for sharing information.
Reporting and recording are major communication techniques used by health care providers to direct client-based decision-making and continuity of care.
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Documentation is defined as written evidence of
The interaction between and among health professionals, clients, their families, and health care organizations
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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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5. Purposes of Health Care Documentation
Communication
Education
Research
Legal and Practice Standards
Reimbursement
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6. Principles of Effective Documentation
Nursing notes must be logical, focused, and relevant to care, and must represent each phase of the nursing process.
Charting in accordance with the nursing process ensures thorough documentation in compliance with ANA’s standards of care, practice acts, and reimbursement and accreditation criteria.
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7. Elements of Effective Documentation
Use of common vocabulary
Legibility
Approved abbreviations and symbols
Organization
Documenting a medication error
Confidentiality
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8. 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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9. Forms for Recording Data
Kardex
Flow sheets
Nurses’ progress notes
Discharge summary
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10. Trends in Documentation
Nursing minimum data sets (NMDS)
Nursing diagnoses
Nursing intervention classification (NIC)
Nursing outcomes
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Reporting
The nurse must consider
What needs to be said
Why it needs to be said
How to say it
What the expected outcomes are
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Types of reporting
Summary reports
Walking rounds
Telephone reports and orders
Incident reports
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