for nursing students unit 5

1. DOCUMENTATION AND REPORTING
ANJANA THOMAS

2. Documentation
 Any written or electronically generated information
 Describe the care or service provided
 It is an accurate account of what occurred and when it
occourred

3. Nursing documentation
 Assessment of patient health status, nursing interventions
 Care plan/ health plan
 Information reported to the physician
 Advocacy undertaken by the nurse on behalf of the patient

4. Record
 Clinical, scientific, administrative and permanent legal
documentation of information related to patient health care

5. Purpose of recording
 Communication
 Quality of care
 Legal documentation
 Planning patient care
 Audit
 Research
 Reimbursement

6. Confidentiality
 Patient confidentiality – legal consideration
 The health insurance portability and accountability act (HIPAA)

7. HIPPA violations
 Gossiping / taking about the patient
 Mishandling the medical record
 Leaving medical record unsecured
 Illegally or unauthorized assessing of patient record
 Sharing information
 Texting or e-mailing on an unencrypted device
 Sharing information on social media

8. Types of patient record
 Patient clinical record
 Medical / nursing record
 Ward record
 Administrative record

9. Patient clinical record
 Knowledge of events involved in the patient’s illness, progress, care
provided
 Patient’s identification and demographic data
 Present complaints
 Informed consent for treatment and procedure
 Admission nursing history
 Family history
 Physical examination findings
 Nursing diagnosis and problems
 Nursing care plan

10. Patient clinical record
 Medical history
 Tentative diagnosis
 Medical diagnosis
 Therapeutic orders
 Treatment given
 Progress notes
 Supportive care given
 Report of diagnostic studies
 Final diagnosis
 Patient education
 Summary of operative procedures discharge plan and summary
 Any specific instructions

11. Medical records
 Legal document providing information of a patient’s medical history and
care by physicians, nurse practitioners and other health care members
 Identification
 Patient health history
 Medical examination findings
 Lab test result, medication prescribed referral orders
 Health instruction to the patient

12. Nursing records
 Progress notes
 Work sheets and kardexes
 Flow sheets
 Intake/ out put section
 Vital signs
 Patient care plan
 E- health record

13. Guidelines for nurse using electronic
records
 Never reveal personal password and ID no
 Immediate inform your supervisor if there is suspicion
 Change password
 Choose password that are not easily deciphered
 Log off when not using
 Maintain confidentiality
 Locate printers in secured areas
 Retrieve printed information immediately
 Protect patient information
 Use system with security

14. Ward record
 Record of reduction or increase in bed
 Admission and discharge
 Linen record
 Indent book
 Rounds book
 Attendance book
 Record book
 Treatment book

15. Administrative record
 Treatment
 Admission
 Equipment losses and replacement
 Personal performance
 Organizational record

16. METHODS OF DOCUMENTATION
 1. Narrative
 2. problem oriented medical record
 3. SOAPIER
 4. PIE
 5. Changing by exception

17. Narrative
 Traditional method
 Story like format
 Specific to patient condition and care
 Data is recorded with out an organization frame work

18. Problem oriented medical record
 Single list of patient problem
 Nursing process forms the basis for the POMR method
 Emphasis on patients problem

19. Advantage of POMR
 Give emphasis to patient’s perception of their problems
 Requires continues evaluation and revision of the care plan
 Greater continuity of care among health care team members
 Enhance effective communication
 Increase efficacy in gathering date
 Provide easy to read information in chronological order
 Reinforces use of the nursing process

20. Components of POMR
 Database
 Problem list
 Plan of care
 Progress notes
 SOAP
 Subjective data
 Objective data
 Assessment
 Planning

21. SOAPIER
 Structured way in which narrative progress notes are written by the health care team
 S- Subjective data – Information obtained from the patient
 O- Objective data - information measured or observed
 A- Assessment – interpretation/conclusion drawn about the sub/obj data
 P- Planning – Plan of care designed for resolve the stated problem
 I- Intervention -Refers to the specifics that have been performed by caregiver
 E- Evaluation – response to the nursing intervention
 R- Revision – care plan modification modifications suggested by the evaluation

22. Problem intervention evaluation (PIE)
 Problem, intervention and evaluation of nursing care
 Consist of a patient care assessment flow sheet and progress notes
 Flow sheet uses specific assessment criteria in a particular format
 Human needs or functional health pattern
 Notes are numbered or labeled according to the patients problem
 Resolved problems are dropped from the daily documentation

23. Focus charting
 Notes that include data, both subjective and objective
 Action or nursing intervention
 Response of the patient
 Notes are structured according to the patient’s concern
 Written in accordance with the nursing process
 Sign or symptoms
 Condition
 Nursing diagnosis
 Behavior
 Significant event
 Change in patient’s condition

24. Charting by exception
 Abnormal or significant findings or exceptions to norms are recorded
 Flow sheet : graphic record, fluid balance record, daily care record, patient teaching
record
 Standards of nursing care : reference to the agencies printed standards of nursing
practice
 Bedside assess to chart form, kept at the patient’s bedside to allow immediate
recording

25. Computerized documentation

26. Computerized documentation
 Used in
 Clinical system
 Management information system
 Educational system

27. Advantages
 Legibility of information
 Increased time efficacy, consistency and accuracy
 Data base for research
 Link various sources
 Patient information, requests and result are sent and received quickly
 Standard terminology improve communication

28. Disadvantages
 No privacy if security measures are used
 System failure
 Expensive
 Need training whenever an updating system installed

29. Electronic health record
 Systematic collection of electronic health information about individual patients

30. Purpose
 Automation and streaming of the workflow in health care setting and
increase safety through evidence- based decision support, quality
management, and outcomes reporting

31. Advantage
 Instant access of all patient information
 Improved efficiencies and provide quality of care
 Help in decision making and ensure that the quality of services
 Maintain highest professional standards

32. Functions
 Health data and information
 Order management
 Result management
 Decision support
 Electronic connectivity and communication
 Patient support
 Administrative process
 Reporting

33. Barriers of EHR
 Technical problems
 Resource matter
 Financial concern - products are expensive and require a major
investment.
 Training
 Concern with privacy

34. Common record keeping forms

35. Guidelines for documentation
 Date and time
 Timing
 Legibility
 Permanence
 Correct spelling
 Signature
 Accuracy
 Sequence
 Appropriateness
 Completeness
 Conciseness
 Accepted terminology
 Legal prudence
 Do not identify the chart by room
number
 Accurate notation
 Avoid general words

36. DO’S DON’T’S
• Should be patient’s name on every sheet
• Check file before any care and charting
• Good skill in English language
• Use concise phrases in notes
• Make entries in serial order
• Use accepted abbreviations
• Should not be torn, back date or rewrite on
the previously added document
• Not to use medical terms, if should not know
exactly
• Not to chart for other staff
• Not to leave the space in between charting

37. REPORTING
 Reports are oral, written or audio taped exchange of
information about the patient.
 It provides information on existing condition of patient.
 Common reports given by nurse include
 Shift report
 Transfer report
 Telephone report
 Incident report
 Reports can be compiled daily, weekly, monthly, quarterly and
annually.

38. Guidelines for reporting
 Factual
 Accurate
 Complete
 Current issue
 Organization

39. Factual
 Report must consist of objective information
 Observe using the senses
 When reports do not have factual observed information, they cannot be accepted
 The exact quotation or words used by the patient must be reported.

40. Accurate
 Whenever reporting any quantity measures report exact amount
 Eg: patient drink adequate amount of water – patient drink 150ml of water
 Data should be concise, clear and easy to understand

41. Complete
 Must be complete containing all essential information
 Care plan information to be entered
 Patient health problem and nursing activities to recored

42. Current
 Information entered in a timely basis.
 24 hour / 12 hour time cycle
 13.00 or 1 pm

43. Organized
 Arranged in logical order
 Order of nursing process
 Assessment, diagnose, goal, plan, implementation, evaluation

44. Criteria of a Good Report
 It can be made promptly
 It should be clear, concise and complete
 All identified data should be included
 Easy to understand
 Important points should be emphasized

45. Purpose of writing report
 To show the kind and quantity of service rendered over to a specific
period
 Show the progress in reaching goals
 To study health condition
 Interpret the services to the public and to other agencies

46. Types of reporting
 1. change in shift report
 It is a report given by a nurse to another due to change in shift
 Provide continuity of care by providing quick summary of assigned patient
 Includes diagnosis of patient, present health condition, treatment and
medication.
 Both the nurses while giving report should assess the patient together
 Types : oral and written report

47.  2. Telephone report
 Include communication about patient’s transfer to another ward and
about patient’s health status
 Common – nurse to nurse, nurse to laboratory, nurse to physician
 Telephone report should be documented, include time of call, who made the
call and to whom information is given.

48.  3. Transfer report
 Related to shifting the patient from one unit to another
 Transfer reports provide continuity of care by providing the
information on telephone.
 It include :
Patient name, age and diagnosis.
Current health status of patient
Any procedure or intervention that need to be performed after transfer
patient to other ward or unit.

49.  4. Incident reports or Accident reports
 Should be complete, clear and accurate as these are legal documents
 Filled in the office of nursing superintendent
 Studied for prevention of such accidents in future

50.  5. Intra division report
 Nurse incharge and bedside nurse
 Between nurse incharge and physician
 Head nurse and administrative supervisors

51.  6. Inter department report
 Reports shared with other department
 Report of patient discharged are send to admission, business office and
information desk

52. Importance
 Employer – Employment, promotion, disposition
 Court of law for various purpose
 Used for a job and leave from work place
 Lawyers used for compensation and liability
 Damage against negligent act
 Execution of will
 Medico-legal reasons
 For use in consumer court

53. Guideline – minimize legal liabilities
 Patient identification data in all pages
 Write clearly and appropriately
 Facts should be based on the observation, conversation and action.
 Select only relevant facts
 Records should be neat, clean, complete and uniform
 Record all telephonic conversation and follow up
 Use standers terminologies and abbreviations
 Do not erase or change any entries
 No individual sheet should be separated
 Correct all mistake as soon as possible
 Record procedure after completion
 Never leave vacant space
 Do not write judgement comments
 Do not destroy the documents

54. Communication in health care team
 Face to face communication
 Written communication
 Consultation
 Referrals

55. Nursing informatics
 French word – informatique – computer science
 The use of computers technology to support nursing, including clinical practice,
administration, education and research

56. Goal
 To improve health of population, communities, families and individuals by
optimizing, information management and communication
 Use the technology in the direct provision of care, in establishing effective
administrative system

57. Functions
 To enhance patient care and nursing practice
 Way of keeping patient information properly organized
 Nurses to make notes that every one can assess
 Help with dosing instructions, staff assignment and lab results
 Help and to create nursing care plan
 Coordinated information help in decision making

58. Framework
 Data
 Information
 Knowledge

59. Importance of nursing informatics
 Increase the accuracy and completeness of nursing documentation
 Improves the nurses workflow
 Eliminate redundant documentation
 Automates the collection and reuse of nursing data
 Facilitates analysis of clinical data
 Access to resources and reference
 Beneficial to nurses and interdisciplinary team
 Administrative – support for cost saving and productivity goals

60. Application
 Nursing clinical practice – point of care system and clinical information
system
 Nursing administration
 Nursing education nursing research

61. Thank you….