documentation and reporting for nursing students. this session deals with important of proper documentation and its legal implications, thus can reduce errors.

2. DOCUMENTATION AND
REPORTING
by,
Midhu M
Lecturer
BCF College of Nursing
Vaikom

3. DOCUMENTATION
Written or typed legal record of all pertinent interaction with the
patient to assessing, diagnosing, planning, implementing and
evaluating.

4. PATIENT RECORD
It is a written or printed communication that permanently documents
information relevant to a client’s health care management

5. REPORTS
• Reports are summary of activities or observations seen,
performed or heard is exchanged among health care team
members, clients and family members.

6. *It provides facts of health services
*provides basis for analysis needs
*basis for short and long term
planning
*prevents duplication of services
*helps the nurse to evaluate care
*Recognize health needs of
individual and family
*used as teaching tool to the
individual and family
*supervise services , activities done
and given
*professional growth
Importance of
report and records

7. PURPOSES
• Communication
• Diagnostic and therapeutic
orders
• Care planning
• Quality review
• Decision making
• Health care analysis
• Education
• Legal documentation
• Reimbursement
• Research
• Historical documents

8. Communication
• Primary purpose
• To communicate between health care professionals
• Prevents repetition and delay
• Improves continuity care

9. Diagnostic and therapeutic orders
• Date and time of order should be documented
• Should be signed by professional staff before execution
• Nurses are responsible for entering orders in patient record
• Record verbal orders, name of physician who ordered, nurses name
and title

10. Care planning
• For plan care
• Nurses using ongoing data
• To evaluate effectiveness of care

11. Quality review
• Client records are reviewed for quality assurance
• JCAHO, NABH are accrediting agencies review client records to
determine whether health care agency meeting its stated standards

12. Health care analysis
• Informations from records help to identify needs of health care
agency
• Over utilized or underutilized hospital services
• Facilitates to generate and compute cost and budgets

13. Education
• Students and health care professionals can learn clinical
manifestation, treatment, diagnostic measures etc from
reading client charts

14. Legal documentation
• Patient records are legal ones
• Used as evidence in court proceedings
• Used in accident or injury claims
• Evidence for charging health professionals for improper care

15. Reimbursement
• After viewing client records reimbursement from medical agency
may be done for client care
• Cost awareness has increased based on care necessary and
implemented

16. Research
• Records are reference material for research work
• Nursing research results in new approaches to client care and
improves professional knowledge

17. Historical document
• Specific dates entering on the record has great value
• Many years later information regarding client health behavior might
be useful to refer

18. Decision making
• Records play an important role for making decision
• Based on previous data future planning, decision can be made

19. Audit
• An audit is a review of records
• An auditor needs records for doing auditing

20. CONFIDENTIALITY

21. • Confidentiality is the respectful handling of information disclosed
within relationship of trust , such as health care relationships
especially as regards further disclosure
• It is vital for the nurse to maintain patient confidentiality when
communicating with patients, friends, their family members and
health care team members
• Patient confidentiality is one of legal consideration for nurses and
nursing students

22. • It is right of an individual to have personal , identifiable medical
information and referred to as protected health information to kept
private
• Due to ongoing advances in technology there is increased risk for
data breach, hacking etc
• HIPAA ( health insurance portability and accounatability act) enacted
in 1996, provides standards for ensuring privacy of patient
information that are enforced by law
• ANA supports recommendations with respect to patient privacy and
confidentiality

23. HIPAA
Privacy rule
Use and disclosure of
individual health
information
Security rule
Set national standards
for protecting
confidentiality

24. Common HIPAA violations
• Gossiping in the hall ways
• Mishandling medical records
• Illegally accessing patient file
• Sharing information with unauthorized people
• Texting or e-mailing patient information on an unencrypted device
• Sharing information on social media

26. Types of
records
Patient clinical
records
Medical and
nursing
records
Ward records
Administrative
records

27. Patient clinical records
• Knowledge of events involved in the patient’s illness, progress, type
of care
• Includes both inpatient and outpatient records
• Records contain following informations like client identification data,
present complaints, informed consent, history, physical examination
findings, diagnosis, treatment, progress notes, diagnostic studies
reports, client education, summary, discharge plan

28. Medical records
• Informations regarding patient’s medical history and care by
physicians, nurse practioners and other health care members
• It contains patient identification data, health history, examination
findings, test results, medications, referral orders, health instructions
to the patient

29. Nursing records
• Includes progress notes, work sheets and kardexes, flow
sheets, I-O charts, vital signs charts, E health records

30. Ward records
• Bed strengths, admission and discharge records, linen record, indent
book, round book, attendance book, treatment record, census record,
complaint book, movement register, drug maintenance register

31. Administrative record
• Includes record of treatment, admission, equipment losses and
replacement ( inventory) , personal performance, organizational
records , written policies, affiliation records, rotation plan, for duties
of staff nurses, budget proposal and allotments, records of committee
meetings

32. TYPES OF REPORTS

33. • Oral report
• Written report
• 24 hours report
• Census report
• Accidental report
• Change of shift report
• Transfer report
• Other report

34. Oral report
• Used in an emergency and followed by a written report later
• Given during time of end of shift or relieve staff

35. Written report
• Concentrate on past, present and future events
• Description and conclusion of action, further planning and
decision making are necessary

36. 24 hour report
• Nursing supervisor and nursing administration personnel
need to be kept informed of what is happening in all patient
care areas

37. Census report
• Number of patients admitted in the hospital
• Helps in planning of health care services and knows about morbidity
and mortality statistics

38. Accidental report
• Writing detailed report on mistakes or accidents taken place in the
care of patients
• Should promptly informed to the higher authorities

39. Change of shift report
• At the end of each shift
• Report information about their assigned clients to the nurses of next
shift

40. Transfer report
• Involves communication of information about clients from the nurse
on the sending to the nurse on the receiving unit
• Following informations also include, clients name, age, primary
doctor and medical diagnosis, summary of medical progress, current
health status, interventions given, needs of any special equipment etc.

41. Incident report
• Nurse who witnessed the incident should file the report
• Describes in concise form what happens in objective terms
• Does not interpret or attempt to explain the cause of the incidence
• Any measures taken by nurse, doctor at the time of incident have to be
reported
• No nurse is blamed in an incident report
• Report is submitted as soon as possible to appropriate authority
• Never make photocopy of the incident report

42. GENERAL PRINCIPLES
• Legal prudence
• Legibility
• Organized
• Continuous
• Date and timing
• Accuracy
• Conciseness

43. • Sequence and timeliness
• Completeness
• Correct spelling

44. Legal prudence
• legal document
• Gives legal protection to nurses, health care professionals
• So it is essential to written clearly, accurately and confidentiality

45. Legibility
• Clear and easily readable by others

46. Organized
• All entries should sign by individual who writes it
• It should in local pattern
• Easily readable

47. Continuous
• With no blank spaces
• If left should be crossed out, dated and signed

48. Date and sign
• Always required date and time after writing records

49. Accuracy
• Each page of record should be properly identified with name, age, IP
no. , bed no. , ward, date etc
• Write only what observed, seen, heard

50. Conciseness
• Should concise and brief
• Use partial sentence and phrases
• Use correct terminology, standard abbreviations

51. Sequence and timeliness
• Timely manner help to avoid errors
• Procedure , treatment , assessment should be recorded as soon as
possible after completion of it

52. Completeness
• Truthful and complete with correct spelling

53. PRINCIPLES OF RECORDING
• Should be written clearly, accurately, appropraiately and legibly
• Should handle carefully
• Develop their own method of expression and form in record writing
• Care to be taken not to make any errors on the records
• If any errors ocuurs, crossed out should be dated and initialed
• For better legibility all records should use black ink or typed

54. CONTINUED..
• Should written immediately
• Records were essential for efficiency and uniformity of services
• Based on relevant facts, brief and accurate

55. PRINCIPLES OF REPORTING
• Should be truthful, accurate, clear, confidential, brief, complete, legible
• Good report indicate efficiency
• Avoid duplication
• To plan future care without wasting time
• Use only standard abbreviations
• All entries should be signed

56. NURSING DOCUMENTATION PRINCIPLES
According to ANA policy,
• Documentation characteristics
• Education and training
• Policies and procedures
• Protection systems
• Documentation entries
• Standard terminologies

57. DOCUMENTATION CHARACTERISTICS
• High quality documentation is accessible, accurate, relevant,
consistent, auditable, clear, concise and complete
• Should be legible, thoughtful, timely and sequential, reflective of
nursing process, retrievable on a permanent basis

58. EDUCATION AND TRAINING
• Regarding technical elements of documentations
• Based on organization policies and procedures related to
documentation
• Competence in use of computer
• Functional and skill ful
• Proficiency in use of software systems

59. POLICIES AND PROCEDURES
• Familiar with all organizational policies and procedures related to
documentation
• For maintaining efficiency

60. PROTECTION SYSTEMS
• Either paper based or electronic
• Based on standards, accrediting agencies, organisational policies and
procedures, confidentiality

61. DOCUMENTATION ENTRIES
• Must be accurate, valid, complete
• Authenticated ( truthful )
• Date and time should include
• Legible / readable
• Use standardized terminologies

62. STANDARD TERMINOLGIES
• Use standard terminology to describe the planning, delivery and
evaluation of nursing care of patient

63. METHODS OF REPORTING
Narrative
charting
Source
Oriented
charting
Problem
Oriented
charting
PIE
charting
Focus
charting
Charting
By excep-
tion

64. Narrative charting
 Traditional method
 Story like format to document specific to patient condition and
nursing care
 Data recorded in progress notes without an organizing framework

65. Source oriented charting
 Descriptive recording done by each member of health care team
 Structured way
 Using SOAPIER (subjective, objective, assessment, plans goals,
interventions, evaluation, revision) format

66. Problem oriented charting
 Emphais on client’s problem
 Each member of health team contributes to a single list of identified
client problems

67. Advantages of
problem oriented
charting
Based on
client’s
perception
Continous
evaluation and
revision

Reinforces use
of nursing
process
Increase
efficiency of
gathering data
Oppurtunity
of care

68.  4 basic components of POMR
 Data base, problem list, plan of care, progress notes

69. Problem intervention evaluation (PIE)
 PIE notes are numbered or labelled according to patient’s problem
 PIE documentation 3 categories – problem , intervention and
evaluation
 Consists of patient care assessment flow sheet and progress notes
 PIE notes are numbered according to patient’s problem

70. Focus charting
 Includes data of both subjective and objective
 Includes action or nursing interventions and response of the patient
 Notes are structured according to patient concerns

71. Charting by exception
 Charting only abnormal or significant findings
 3 key elements – flow sheets, standard of nursing care, documentation
by reference to the agencies
 All flow sheets are kept at patient’s bed side

72. Guidelines of documentation
 Correct identification data of patient
 Document as soon after care/procedure
 Enter date and time
 Never change another persons entry
 Don’t record in advance
 Use quotations for a direct patient response
 Document in chronological order
 Use authorized abbreviations
 Donot erase, apply correction fluid

73.  Don t write critical comments/ suggestions
 Record all facts
 don't leave blank spaces
 Record legibly using black/blue
 Start each entry with date and time and end with signature
 Concise and brief
 For computer documentation keep your password safe

74. COMMON RECORD-KEEPING FORM
 A variety of forms are used to document client’s health status, problems,
interventions, response to interventions. These are the following:
 NURSING HISTORY: Nursing history is completed when client is admitted to
hospital. This form includes a complete assessment of client to identify relevant
nursing diagnosis. Information recorded on this form provides a baseline data which
can be compared with changes in client’s condition.
 GRAPHIC SHEETS & FLOW SHEETS: Flow sheets have vertical & horizontal
columns for recording data, times to show assessment & interventions. This help to
identify changes in client’s condition. It is used to document vital signs, IV therapy,
routine repetitive care such as meals, weight. It is very important to fill the flow
sheets otherwise spaces reflects no intervention carried out

75.  NURSE’S PROGRESS NOTES: It includes client’s condition problems,
complaints, interventions & achievement of goal & outcomes. Progress notes
include following forms:
 Nurse’s progress notes can be completed in narrative form.
 Standardized Care Plan

76. Sample of written report
BED. NO. NAME & DIAGNOSIS DAY REPORT
13. Rani, F/36 yrs/ Bronchial
Asthma
New admission
The patient was received from
the emergency at 11am. On
the admission the patients
general condition was fair.
Temp ,Pulse, respiration were
990 F, 100/min & 26/min
the patient was having
breathing problem, had
meals. all the medicines, as
prescribed by the doctor, are
given, o2 inhalation to be
given s.o.s.

77. CARE OF RECORD
 Records kept under custody in a place which is not accessible to the patient
& his/ her relatives but accessible to doctors & nurses
 No stranger is allowed to read the record
 Records not to be handed over even to the legal advisor without the written
permission of the administrator.
 Records to be arranged in alphabetical, numerical, geographical orders &
with an index card .this records may be maintained by the record room.
 See that the records of the patient is well maintained, complete & signed by
the doctor before sending to the record room, take the signature of the
person receiving the record & see that the patients name, age, ward no, bed
no, OPD no, diagnosis & treatment entered.

78.  Complete
 Logically organized
 Client’s identifying information must be written on each page of the
client’s record. Nurse must ensure that she is writing notes on right
client’s record.
 While making entry on record it must be started with complete
date(month, time, year).
 Nurse should never edit or delete the documentation done by other
personnel
 At the end of nursing notes line can be drawn from end of text to end
of right margin on line so that no one else can add documentation.

79.  Documents must be signed by nurse at the end of entry
 Never leave empty space between entries as someone else can
add.
 While documenting follow the hospital policy.

80. DO'S AND DON'TS OF NURSING
DOCUMENTATION
 Nurses are well aware of the standard, which states that if a
certain matter affecting patient care is required to be charted
and it is not, the overwhelming presumption is that it may
not have been done. Good documentation will help you to
defend yourself in a malpractice lawsuit, it can also keep you
out of court in the first place.

81. DO’S
 Check that you have the correct chart before you begin writing.
 Make sure your documentation reflects the nursing process and
your professional capabilities.
 Write legibly.
 Chart the time you gave a medication, the administration route,
and the patient's response.
 Chart precautions or preventive measures used, such as bed rails.
 Record each phone call to a physician, including the exact time,
message, and response.

82. CONTINUED……
 Chart patient care at the time you provide it.
 If you remember an important point after you've completed your
documentation, chart the information with a notation that it's a
"late entry." Include the date and time of the late entry.

83. DON’T
• Don't chart a symptom, such as "c/o pain," without also charting
what you did about it.
• Don't alter a patient's record - this is a criminal offense.
• Don't use shorthand or abbreviations that aren't widely
accepted.
• Don't write imprecise descriptions, such as "bed soaked" or "a
large amount."

84. CONTINUED……
• Don't chart what someone else said, heard, felt, or smelled
unless the information is critical. In that case, use
quotations and attribute the remarks appropriately.
• Don't chart care ahead of time - something may happen and
you may be unable to actually give the care you've charted.
Charting care that you haven't done is considered fraud

85. COMPUTER DOCUMENTATION
 Strongest trends in nursing documentation
 Using – nursing care plan, supplies, equipment, stock medicines and
diagnostic testing
 Contain all informations found in traditional records
 Repetition can be eliminated
 In Nursing, computer documentation can be divided into 3 categories-
clinical systems, management information system, education system

86. Advantages Disadvantages
 Time conserving
 Consistent, legible and accurate
 Helps in research
 Link to various sources of
patient information
 Information can be easily
transferred
 Increase legibility
 Enhance critical thinking and
decision making
 Confidentiality issues
 Requires training
 System failure cause loss of
information
 Expensive

87. Legal guidelines of nursing administration
 Understand nursing practice acts
Nursing practices regulated by federal and state laws
State laws – nursing practice acts
State regulatory agencies – holding a license as a Nurse in state for
competent in practice

88.  Keep the audience in mind
Nurse should aware about whom are reading documents
Health care team members , the scribe, lawyers and experts, judge and
jury

89.  Should maintained properly because it is a legal evidence for nurses to
prove their innocence and professional responsibilities
 Must report abuses, wound, suicides and infectious diseases to concern
personnel
 Nursing record may required by various puroses like employer, court of
laws, leave and job purposes, compensation and liabilities, damage
against negligence, execution of will, medico legal cases, consumer
court

90. Legal implication in documentation
 Informed consent before investigation/ surgery
 Confidential record/ report shown only to authorize person
 Registration of birth, death, like vital events
 Check labels before administration of medications
 Medication should administer as per physician order
 Record and report unusual incidents, errors

91. MINIMIZE LEGAL LIABILITIES
In hospital setting, physicians, nurses are also involved in cases of medical
malpractice, negligence, personal injury. Now days public is very much aware of
their rights. Every client expects best quality care in hospitals. Documents are the
best black & white print which reflect the care provided. Thus while documenting
any word, nurse should consider the possibility that client’s record may be
submitted to the court as a source of information regarding client’s condition &
nursing care. So in order to minimize legal liabilities document should have
following characteristics.
 Factual
 Accurate

92.  Correct patient identification data on each page of record
 Clear and appropriate
 Based on observation, conversation and action
 Only relevant facts
 Neat , clean, complete and uniform
 Record all telephonic conversation and followup instructions
 Use common medical terms and std abbreviations

93.  No individual sheet should separate
 Correct all mistakes as soon as possible
 Never leave vacant spaces
 Don’t write critical judgements
 Don’t destroy documents without prior permission

94. Contd…..
 Patients record never sent out of the ward without doctors
permission.
 If the patient is transferred to the another hospital, the nurse
should see that a complete summary is made in a separate paper
to be sent with the patient & not the original record.

95. Role of a Nurse
 What should be documented
 Baths and daily hygiene
 Skin care
 Turning and repositioning
 ROM exercises
 Any important communications with the patient

96.  Observe and document
 Changes in patient awareness and mental state
 Vital signs
 Urine output
 Bowel movements
 Skin colour and warm
 Unusual behaviour that patients says

97.  FACT criteria
 Factual and accurate

98.  Daily charting
 LOC
 Vital signs
 I-O
 Bowel activity
 Oral intake
 Skin colour
 Patient behaviour
 Activity level
 Patient weight
 Updating daily details

99. Common documentation errors
 Sloppy or illegible hand writing
 Failure to date, time and signature
 Lack of documentation for omitted medication / treatment
 Incomplete or missing documents
 Adding entries later on
 Documenting subjective data
 Not questioning incomprehensible orders
 Using wrong abbreviations
 Entering informations into wrong chart

100. Common reports using by Nurses
 Shift report
 transfer report
 telephone report
 incident report

108. “if you haven’t document it, which means you haven’t
done it”….

110. SUMMARY

111. CONCLUSION

112. REFERENCES
• Francis C . fundamentals of nursing lotus pub. 1st ed, 2017 pg no. 96-107
• Goyal H , textbook of nursing foundation, CBS pub, 1st ed, 2020. Pg
no.107-114
• Clement I . nursing foundation – 1 , jaypee pub, 1st ed,2022. Pg no.164-186