Nursing Documentation and Reporting - A simple learning for Nurses.
AUTHOR : ARMRITA
About Nursing Documentation and Reporting :
Nursing documentation is a vital component of safe, ethical and effective nursing practice, regardless of the context of practice or whether the documentation is paper-based or electronic. This document is intended to provide registered nurses (RNs) with guidelines for professional accountability in documentation and to describe the expectant for nursing documentation in all practice settings, regardless of the method or storage of that documentation. The main aim of the document is to assist the registered nurse to meet their standards of practice related to documentation.
Documentation is the permanent recording of information properly identified as to time, place, circumstances and attribution.
Documentation is the written, legal record of all pertinent interactions with the client-assessing, diagnosing, planning, implementing and evaluating.
To write (something) down so that it can be used or seen again in the future; to produce a record of (something).
It is oral, written or computer based communication intended to convey information.
Purposes of Recording and Reporting :
1. Decision Making.
4. Legal accountability.
10. Historical document.
11. Quality assurance.
12. Vital statistics.
13. Health service planning.
14. Diagnostic and the therapeutic orders.
15. Accrediting and licensing.
Purposes of Recording and reporting :
Decision Making :
Records play an important role for making decision. Based upon the previous data, future planning, decisions can be made.
Records are tools of communication among the members of the health team to promote continuity of care among departments throughout 24 hours of care and during the entire hospital stay.
After viewing the clients records the reimbursement from the medical agency may be done for client care. Cost awareness has increased the emphasis on what care is necessary and no care is to be implemented.
The student in health discipline like medical, dental, BPT, Nursing views the clients record as an educational tool in their clinical experience and these records can frequently provide data for care studies. They can learn a great deal about the clinical manifestations of particular diseases, specific investigations effective treatment modalities and clients responses towards treatments.
Legal Accountability :
The client record is a legal documentation and it is usually administrable in a court as an evidence, especially in medico legal cases. The record safeguards the clients, nurses, doctors and the hospital. The record should document clients at risk and safety measures implemented.
Nurse and other health care members gather assessment data from the clients records by studying clients history and in initial assessment and comparing this data with additional subjective and objective information that has been obtained, current health status and progress towards goal can be determined.
The nurse use baseline and ongoing data to plan nursing care.
Records serve as a reference material for research work. Nursing research results in new approaches to client care and it increases professional knowledge.
Historical Document :
As there are specific dates of entries on the clients record, this has a great value as a historical document. Many years later, information regarding clients health care behaviour might be pertinent.
Quality Assurance :
As part of quality assurance programmed health care agencies periodically conduct chart audits to determine whether or not the care provided meets the established standards of client care and financial information about which service generates revenue etc.
An audit is a review of records. Auditor needs records for doing auditing.
Vital Statistics :
Records are used especially for assessing mortality and morbidity rate.
Diagnostic and the Therapeutic Orders :
Nurses are responsible for ensuring diagnostic and therapeutic orders that are entered in the clients record and implemented.
Health Service Planning :
Data taken from the clients record point out the health problems of the country and it also provides a baseline in which local, state, national and international services are planned.
Accrediting and Licensing :
Record keeping is basis of good patient care. Thus, it should be integral to all practices.
Types of Records :
1. Ward Records
2. Nurses Records.
3. Education Records.
4. Administrative Records.
Ward Records :
1. Patients Clinical Record :
It includes outpatient records and inpatient records. In most of the hospitals, the inpatient record will be the continuation of the outpatient record. It will be filled up in the outpatient department. This will contain the bio-data of the client, diagnosis, investigation results, treatment and so on.
2. Doctor Order Sheet :
Doctors order regarding treatments, medications, investigation, diet may be written on separate sheets.
3. Reports of Laboratory Examination :
Normal values included in this for evaluating abnormalities.
4. Diet Sheet :
It includes type of diet depends on the patients diagnosis. E.g. for diabetic patient sugar-free diet.
5. Consent Form for Operations and Anesthesia :
Before going to do any treatment or surgery onsent to be taken from the patient or any responsible person from the patient side.
6. Intake and Output Chart :
Intake of the patient includes IV fluids, oral fluids, ryles tube feedings, gastrotomy tube feedings. I/O chart maintained in clients with critical illness, diarrhea, diuretics, after surgery.
7. Reports of Physiotherapy, Occupational Therapy
8. Kardexes :
It is recording of clients data after organization, making information quickly accessible to all health personnel.
9. Instruction Book :
The doctors give special instant instructions when any incident happens suddenly during rounds, e.g. if the patient gets acute abdominal pain, doctor instructs to post the client immediately for appendicetocmy.
10. Admission and Discharge Record :
Record the name, age, sex, address of the client, date and time of the admission, diagnosis of the client. It gives the record of total number of admissions per day. When the patient is discharged, the date and time of discharge is entered.
11. Census Record :
It includes the total number of admission, discharges, transfer-ins, transfer-outs, absconding and deaths of the client.
12. Call Book :
It includes the name of the doctor, date, time and purpose of the call in emergency situations.
13. Complaint Book :
It consists of any repairs in the ward like machinery, electricity and water supply.
14. Movement Register :
It gives the information regarding the availability of doctor and nurse concerned. E.g. place where they are available at that particular time.
15. Indent Book :
The total number of linen, medicines, IV fluids, cotton, gauze is indented for the patients care.
16. Drug’s Maintainance Register :
The prescription and supply of drugs generates a variety of records including pharmacy stock ordering, dispensing records, request for drugs from stores, drug administration records, prescription for individual patients, the receipt and issue of all drugs should be recorded.
The name, age, sex, address, diagnosis, date and time of the death of the clients is written in red ink, also recorded whether the dead body is sent to the mortuary or handled over to the relatives and their signature.
Nurses Records :
The office of the chief nurse will generate records of the type found in the office with an executive or administrative function: correspondence, reports, minute of meetings. In the wards, nurse may maintain admission registers. The following points will serve as a guide in selecting the important.
Symptoms that are intense in character. E.g. a colicky pain.
That persists over a long period.
That indicates a change in the condition of the patient.
An impairment or loss of function of an organ or a part of the body.
That recurs at regular or stated intervals.
That becomes progressively more severe.
That may indicate development of complications.
That requires treatment beyond the ordinary nursing measures.
Graphic Charts of TPR :
On this the temperature, pulse, respirations are written in a graphic form so that a slight deviation from the normal can be noted at a glance. Other information such as BP, number of bowel movements, urinary output, the body weight, name and date of operation, removal of sutures etc. May be recorded on this chart.
Educational Records :
The officers, boards and committee of medical and nursing schools will produce their own records, minutes, correspondence, reports and so on.
Educational records may also be found if there is a teaching component within the hospital.
E.g. letters of appointment, joining reports, job description, service record of staff members.
Administrative Records in Nursing Superintendent’s Office :
Hospitals also requires records relating to finance, personnel, building, accomodation, stores and other such services, although they will be little different from those used in non-medical organizations of equivalent size. Besides these records, annual and statistical reports will probably be prepared, providing summaries of hospital activity.
1. philosophy, purposes and curriculum.
2. Course, content and course plan record for each subject.
3. Rotation plan for duties of staff nurses.
4. Minutes of committee meeting.
5. Record of committee.
6. Record of academic requirement.
7. Stock register.
8. Annual reports.
9. Affiliation records.
10. Written policies.
11. Statement of budget proposal and allotments.
12. Copy of brochure.
13. Photography/video/paper cuttings of important events.
Principles of Record Writing :
1. Legal Prudence :
Since the clinical record is a legal document and gives legal protection to the nurse, other health care professional of the institution, it is essential that they should be written clearly, accurately and confidentiality maintained.
2. Legibility :
Writing must be clear and easily readable by others.
3. Organizations :
Documentations on data collection should be organized in a local pattern, as the statement is more easily read.
4. All entries should be signed by the individual who writes them.
5. Records are written continuously :
With no blank spaces. If any space is left out, it should be crossed out, dated and signed.
6. Date and Sign :
When recording medications and treatments, note exact time and date on which they are carried out.
7. Accuracy :
Each page of the record should be properly identified with the name, age, I.P. No, Bed No, ward, date etc. Write observations the individual has seen, heard, spelled or left. Sometimes for adequacy a photograph can be utilized.
8. conciseness or Brevity :
Good charting is concise and brief. Use partial sentences and phrases, drop the clients name and terms referring to the client. Nurses must utilize correct terminology and use only standard abbreviations.
9. Sequence and Timeliness :
Documentation on is the timely manner can help to avoid errors. Procedures, treatments and assessments should be recorded as soon as possible after their completion.
10. Completeness :
Record should be truthful and complete. It should include all the services given to the patients and the observations made on the patients from day-to-day.
Correct Spelling :
In case of doubt, check the dictionary and use the correct spelling.
Methods of Recording :
1. Narrative Charting :
It is a traditional method for recording nursing care provided. It is a story like format to document information specific to client conditions and nursing care.
2. Source - Oriented Charting
Descriptive recording done by each member of health care team on separated parts. One of the most prominent features of this problem-orientated method of documentation is the structured way in which narrative progress notes are written by all health-care team members, using the SOAP, SOAPIE OR SOAPIER format.
Subjective : the clients observation.
Objective : the care providers observations.
Assessment : the care providers understanding of the problem.
Plans Goals : action, advice intervention when an intervention was identified and changed to meet clients needs.
Evaluation : how outcomes of care are evaluated.
Revision : when changes to the original problem come from revised.
3. Problem - Oriented Charting :
This is a method of documentation that places emphasis on clients problem. Here, each member of health team contributes to a single list of identified clients problems.
The nursing process forms the basis for the POMR method of documenting clients problems listed the advantages of this method of documenting are as follows :
Gives emphasis to clients perceptions of their problems.
Requires continuous evaluation and revision of the care plan.
Provides greater continuity of care among health-care team members.
Increases efficiency in gathering data.
Reinforces use of the nursing process.
4. PIE Charting :
The key components of the system are assessment flow sheets and nurses progress notes with plan of care.
The PIE notes are numbered according to the clients problem. Resolved problems are dropped from daily documentation after the RNs review.
5. Focus Charting :
Focus charting is the method of identifying and organizing the narrative documentation of clients concerns. This method of documentation consists of notes that includes data, both subjective and objective; action or nursing interventions; and response of the client. The notes are structured according to clients concerns.
A sign or symptom
A nursing diagnosis
A significant event
A change in clients condition.
6. Charting by Exception :
Is a charting method that requires nurse to record only deviation form established norms.
Key elements required for CBE are :
Practice setting documentation policies and protocols.
Assessment norms, standards of care.
Individualized care plans.
Unique flow sheet.
Beside accessibility of documentation forms it is not acceptable to use documentation by exception unless these exist.
7. Graphic Sheets and Flow Sheets :
Health care record entries should reflect the most recent assessment, as they are done, to ensure treatment decisions are based on accurate information. If documenting on a flow sheet or checklist, check marks may be used as long as it is clear who performed the assessment or intervention. The meaning of check mark or symbol used must be identified in the practice setting policy.
Reporting is the verbal or written communication of data regarding the clients health status needs, treatments, outcomes and responses. Reporting facilitates clinical decision making, continuity of care and co-ordination among health team members.
The reports used in hospital setting usually are :
1. change - of - shift reports
2. Transfer reports.
3. Incident reports.
1. Change - of - Shift Reports :
These may be given orally in person by audio taping, recording or during rounds at clients bedside some of the points to be kept in mind while giving such reports are as follows:
Provide only essential background information about client but do not review all routine care procedures or tasks.
Identify clients nursing diagnosis or health care problems and other related causes but do not review all biographical information.
Describe objective measurements about client condition and response to health problems but do not use critical comment about clients behavior.
Continuously review ongoing discharge plan. Don’t engage in idle gossip.
Evaluate results of nursing or medical care measures. Do not simply describe results as good or poor. Be specific.
Be clear on priorities to which on coming staff must attend. Do not force oncoming staff to guess what to do first.
2. Transfer - Reports :
Patient will frequently be transferred from one unit to another to receive different levels of care. When giving transfer request, the nurse should include the following information.
Clients name, age, primary doctor and medical diagnosis.
Summary of medical progress upto the time of transfer.
Current health status - physical and psycho-social.
Current nursing diagnosis or problems and care plans.
Any critical assessment or interventions to be completed shortly.
Needs for any special equipment etc.
3. incident Reports :
Nurses usually become involved in client-related incidents as some points in their careers. They must understand the purpose of incident reports and the correct way to report information.
While incident reporting, the following points are to be kept in mind.
The nurse who witnessed the incident or who found the client at the time of incidence should file the report.
The nurse describes in concise form what happens specially objective terms.
The nurse does not interpret or attempt to explain the cause of the incidence.
The nurse describes objectively the clients conditions when the incident was discovered.
Any measures taken by the nurse, other nurses or doctors at the time of the incident are reported.
No nurse is blamed in an incident report.
The report is submitted as soon as possible to the appropriate authority.
The nurse should never make photocopy of the incident report.