Documentation and

Reporting in Nursing

By: Bryan Mae H. Degorio

Documentation
- is defined as anything written or printed
that is relied on as record or proof for
authorized persons
- effective documentation reflects the
quality care and provide evidence for
healthcare members accountability in giving
care

Medical Record or Chart

- is an account of the clients health history,
current health status, treatment and
progress
- is a highly confidential legal documents
by
which nurses, physicians, and other
team
members communicate about the
client

Multidisciplinary Communication Within Healthcare

1. Reports
- includes both the oral and written exchange of
informations between caregivers intended to
convey information to other.
2. Consultations
- is a form of discussion whereby one
professional caregiver gives formal advise
about the care of a client to another caregiver
3. Discussion
- is an informal oral consideration of a subject
by
two or more healthcare providers to
identify problem or established strategies to
resolve a problem

Purposes of Documentation:
1. Communication
2. Planning patients care
3. Legal documents- the clients record is legal
document and is admissible to
court.
- CARE NOT DOCUMENTED IS CARE
NOT DONE
- Common Problem in Documentation
a. Not charting the correct time when evens
occurred
b. Failing to records verbal orders or failing to
them signed
c. Charting actions in advance to save time
d. Documenting incorrect data

4. Research
5. Education
6. Quality assurance monitoring/Auditing

monitoring
7. Statistics
8. Reimbursement
9. Financial Billing

Types of Records
1. Temporary records
- these are temporary records use to
facilitate communication to maintain
information for easy accessibility
- must be updated whenever there is a
change in the patients plan of care
ex. - vital signs list
- white board notation
- bedside turning records
- medication card

2. Permanent records

- it can be paper chart or a

computerized
record
a. paper chart- a permanent record of
the
clients healthcare
b. Computerized record- it allows to
quickly
enter specific assessment
data
and information and retrieval
of data

System of Organizing Contents:

1. Source-oriented Records (SOR)

- the client chart is organized so that each

discipline has a separate part in which to
record the data
- components:
a. Admission sheet
b. Physician order sheet
c. Medical History
d. Nurses notes
e. Special records or reports

2. Problem Oriented Clinical Records (POCR-

POR)
- the data about the client is recorded and
arranged according to the problem
the
client has rather than according to
the
source of informations
- Components:
1. database- contains all the available
assessment
information pertaining to
the client
- it is subjected for revision
2. Problem list- is a list of problem that is
carefully
compiled once the database
had been
collected and analyzed

- each problem is labelled and numbered so

that it can be identified throughout the records
- it can be active or inactive
- when several problems have common
etiology 2 methods are being used:
a. Sub-listing- is a group of all manifestations of a
major problem that requires separate management
ex. I- Vehicular accident
IA- Self-care deficit
IB- Impaired mobility
IC- Total Incontinence

b. Cross-referencing method- lists all

problems
separately using consecutive
number
- aProblem
Related
to on the
right
list
Related to
ex.
1. CVA
2. Self-care deficit

#1

3. Impaired Physical
Mobility

#1

c. Redefinition- is necessary to reflect a

change in
the client problem

3. Initial list of orders or Nursing Care Plan

- is generated by the person who list the

problem
- Medical Care plan
Nursing Care Plan
4. Progress Notes
- healthcare team monitor and record the
progress of a clients problem
- ways of writing progress notes:
a. SOAP/SAPIE/SOAPIER
b. PIE format
c. Focus Charting
d. Charting by Exceptions

1. SOAP/SOAPIE/ SOAPIER

S- Subjective- consists of all the informations

obtained from the client
O- Objective- consist of information that are
obtained and measured by the senses
A- Assessment- is the interpretation or
conclusion
drawn form the subjective and
objective data
- is the statement of the
clients problem
P- Plan- is a plan of care designed to resolve
the problem
I- Implementation- specific interventions
actually
been performed by the caregiver

E- Evaluation- clients response to the

nursing and
medical interventions
R- Revisions- reflects care plan modification
suggested by the evaluation

2. PIE format

- it groups information into 3 Categories

- P- refers to the specific problems using
NANDA
- if no approved diagnosis- utilize the
HRA
format
I- Interventions- employed to manage
the
problem
E- Evaluation- is the effectiveness of the
interventions

3. Focus Charting

- is intended the client and the client

concerns to be the focused of care
- Format:
D- data (both subjective and objective
data)
- reflects the assessment phase of the
nursing process and consists of
observation
of client status and
behaviour including the
data from the
flow sheet
A- Action (Nursing Interventions)
- reflects planning and implementation
and
includes immediate and future
nursing
action

R- Response
- reflects the evaluation phase of the
nursing process and describe the client
response to nay nursing or medical
interventions
4. Charting by Exception
- is a short hand method for
documenting
normal findings and
routine care based
clearly defined
standards of practice and
pre-determined
criteria for nursing
assessment and
interventions

- the nurse write progress notes only

when
the standardized statements on the
form is
not met
- Components:
a. Unique flow sheet with pre-determined
assessment parameters and findings
b. Documentation by reference to the
standards
of nursing practice
c. Bedside accessibility of documentation
form

Common Record Keeping Forms

1. Nursing Health History

- it is completed during the admission of

the client
- it provide baseline data that can be
compared with changes in the client
condition
2. Nursing Kardex
- is a from or card that is kept in a potable
flip- over file or notebook at the nurse
station
- it as a tool for the change-of-shift report

-data available in the Kardex

a. Personal data
e. Daily nsg procedures
b. Basic needs
f. Medication IV
c. allergies
g. ttt
d. Dx test
3. Graphic sheets and flow sheets
- these are forms that allow nurses to
assess the
client and document routine
repetitive care quickly
- it includes: graphic sheets, I and O
sheet,
medication and daily
nursing care

4. Nursing Care Plan

- 2 types:
a. Traditional care plan
b. Standardized care plan
5. Discharge and Summary Forms

- it contains information with emphasis on

preparing the client for efficient, timely
discharge from a healthcare institution
- discharge summary includes:
a. Description of the clients condition
upon
discharge
b. Current health medication

c. treatment
d. diet
e. Activity level
f. Restrictions
6. Discharge Against Medical Advice/ HAMA or

AMA
- these are use by the agency to those
client who leave the institution without the
permission of the physician

Characteristics of Good Recording

1. Timing
2. Confidentiality
3. Permanence

- all entries in the chart are made in dark

colored ink so that the record is permanent and
changes can be identified
4. Signature
- each recording on the nursing notes is signed
by
the nurse making it.
- include the NAME and the TITLE
- affix the signature and place at the end of the
charting at the right margin of the nurses notes

5. Accuracy

- accurate notations consist of facts or

exact observation rather than opinions of
an
observation
ex: Correct
Wrong
Ate 50% of food served

Ate with fair appetite

Intake of 360 ml

Drank an adequate
amount of fluid

Refused medication

Uncooperative

- place client complaint in quotation

- ERROR in charting
- if BLANKS APPEARS IN NOTATION

6. Sequence and Organizing

- document event in the order in which it

occurs and notes should appear in each
succeeding line.
- avoid DOUBLE CHARTING
- avoid squeezing informations into a
space in
between
7. Appropriateness
- only information that pertains to the
client health problem and care is recorded
8. Completeness
- the information that is recorded needs to
be
complete and helpful to the client and
health care provider

- the following informations should be

charted:
a. Physicians visit
b. Times the patient leaves and return to
the unit
and mode of transportation and
destination
c. Medication should be charted
immediately
after given
d. Treatment should be charted
immediately after
given
9. Use of standard terminology
10. Brevity
- entries are concise
- start with capital and end with a period

10. Legal Awareness

- chart only what you have personally

have done, observed, heard, smelled and
felt
11. Do not use the word Pt in the chart

Types of Reporting
1. Change-of-sift report/Endorsement

- is an oral report given 2-3 times a day by

the nurses to all nurses on the next shift
- purpose: continuity of care
- bases: healthcare needs
- ways of reporting:
a. Face to face
b. Audiotape recording
c. Walking endorsement

2. Telephone Reports

- use to inform physician of changes in

clients condition, transfer to another unit
and relay lab result
- should provide clear, accurate and concise
information
- document the following in telephone orders:
a. When the call was made
b. Who made the call
c. Who was called
d. To whom the information was given
e. What information was given
f. What information was received

3. Telephone Orders

- is usually given during night and

emergency situation only
- guidelines for T.O.
a. Repeat the prescribed order back to the
physician
b. Write the T. O. including the date, time
given, name of the client, nurse and
physician and the complete order
c. Allow the physician to sign the order
within 24
hours

4. Transfer report

- done when transferring client from one

unit another
- it should include the following:
a. Clients name, age, primary physician and
medical
diagnosis
b. Summary of the progress up to the time of
transfer
c. Current health status
d. Current plan of care
e. Any critical assessment or interventions to
be
completed shortly after transfer
d. Any special consideration
e. Needs for equipment