2. • Documentation is anything written or printed on
which you rely as record or proof of patient
actions and activities.
3. • A record or chart or client record, is a formal,
legal document that provides evidence of a
client’s care and can be written or computer
based.
4. • A report is oral, written, or computer-based
communication intended to convey
information to others.
5. • The process of making an entry on a client
record is called recording, charting, or
documenting
6. • Each health care organization has policies
about recording and reporting client data, and
each nurse is accountable for practicing
according to these standards.
7.
8. Purposes:
• The patient record is a valuable source of data for all
members of the health care team.
• Client records are kept for a number of purposes
including:
Communication
Planning client care
Auditing health agencies
Research
Education
Reimbursement
Legal documentation
Health care analysis
9. Communication
• The record serves as the vehicle by which different
health professionals who interact with a client
communicate with each other.
• This prevents fragmentation, repetition, and
delays in client care.
10. Planning Client Care
• Each health professional uses data from the
client’s record to plan care for that client.
• Nurses use baseline and ongoing data to evaluate
the effectiveness of the using care plan.
• The physicians plans treatment after seeing the
laboratory reports of patient.
11. Auditing Health Agencies
• An audit is a review of client records for quality
assurance purposes .
• Accrediting agencies such as The Joint
Commission may review client records to
determine if a particular health agency is meeting
its stated standards.
12. Research
• The information contained in a record can be a
valuable source of data for research.
• The treatment plans for a number of clients with
the same health problems can yield information
helpful in treating other clients.
13. Education
• Students in health disciplines often use client
records as educational tools.
• A record can frequently provide a
comprehensive view of the client, the illness
and effective treatment strategies.
14. Reimbursement
• Documentation also helps a facility receive
reimbursement from the government.
• For a patient to obtain payment through
Medicare or insurance agencies the client’s
clinical record must contain the correct
diagnosis and reveal that the appropriate care
has been given.
15. Legal Documentation
• The client’s record is a legal document and is
usually admissible in court as evidence.
16. Health Care Analysis
• Information from records may assist health care
planners to identify agency needs, such as over
utilized and underutilized hospital services.
• Records can be used to establish the costs of
various services and to identify those services
that cost the agency money and those that
generate revenue.
18. • In today’s health care system, delivery
processes involve numerous interfaces and
patient handoffs among multiple health care
practitioners with varying levels of educational
and occupational training.
• During the course of a 4-day hospital stay, a
patient may interact with 50 different
professionals, including physicians, nurses,
technicians, and others
19. • Lack of communication creates situations
where medical errors can occur. These errors
have the potential to cause severe injury or
unexpected patient death.
• Effective communication takes place along
two approaches.
1. Recording
2. Reporting
20. All records contain the following information:
• Patient identification and demographic data
• Informed consent for treatment and procedures
• Admission data
• Nursing diagnoses or problems and nursing or
interdisciplinary care plan
• Record of nursing care treatment and evaluation
• Medical history
• Medical diagnoses
• Therapeutic orders
• Medical and health discipline progress notes
• Physical assessment findings
• Diagnostic study results
• Patient education
• Summary of operative procedures
• Discharge plan and summary
21. • Reports are oral, written, or audio taped exchanges
of information among caregivers.
• Common reports given by nurses include change-of-
shift reports, telephone reports, hand-off reports,
and incident reports.
• A health care provider calls a nursing unit to receive
a verbal report on a patient’s condition.
• The laboratory submits a written report providing
the results of diagnostic tests and often notifies the
nurse by telephone if results are critical.
22. • Team members communicate information
through discussions or conferences.
• For example, a discharge planning conference
involves members of all disciplines (e.g., nursing,
social work, dietary, medicine, and physical
therapy) who meet to discuss the patient’s
progress toward established discharge goals.
23. Importance of communication within health team
• It helps in planning comprehensive quality care of client as
every member gather different information
• Sharing information helps to verify the clues; thus reducing
ambiguity
• It also avoids duplication of efforts in collecting data
• Helps the team members to benefit from the information
others have collected
• Helps in the achievement of goal, by keeping all the
members in one track
• Ensures coordination between the health team members
• Communication is done through many ways and help the
members to be up-to-date in patient’s progress
24. Communication media
• Communication media is way by which
information is shared.
• Communication media commonly used in
medical field
– Reports
– Consultation
– Referrals
– Patient rounds
25. Reports
• Reporting is a means of sharing the brief
information about the event that recently
occurred.
• It is done to convey information regarding
clients health status that is progress or
deterioration
• Reporting is also used to alert the members
for the care of specific patients
• Reporting can be done verbally or written
26. • Reports can be compiled daily, weekly, monthly,
quarterly and annually.
• Report summarizes the services of the nurse and/ or
the agency.
• Reports may be in the form of an analysis of some
aspect of a service.
• These are based on records and registers and so it is
relevant for the nurses to maintain the records
regarding their daily case load, service load and
activities.
• Thus the data can be obtained continuously and for a
long period.
R S MEHTA, MSND 26
27. consultation
• It means taking the opinion of some
specialist/exports
• Nurses usually consult peers, incharge nurse,
physician, specialized nurse regarding client’s
plan of care or progress
• Even physician also consults other physician to
see patients and to give opinion regarding
diagnostic or therapeutic measures
28. Referrals
• A referral system plays an important role in
assuring continuity of care
• It is the responsibility of a nurse to assure that
referral form is filled and completed
• Within the hospital client’s record should be
available to the member of department to whom
client is referred
• Referring a client to other department within
the agency
• Referring a client to another agency
29. Rounds
• It is the best way of communicating
information about client
• During rounds information exchanged,
suggestions are taken regarding client’s
progress and plan for care
30. RECORDS
A record is a permanent written
communication that documents
information relevant to a client’s
health care management, e.g. a
client chart is a continuing
account of client’s health care
status and need.
-Potter and Perry
30R S MEHTA, MSND
31. TYPES OF RECORDS
• Ward records
• Nurses records
• Students records
• Staff records
• Academic and Administrative records
32. Ward records
• Patient’s clinical record
• Doctor order sheet
• Reports of laboratory examinations
• Diet sheet
• Consent form for operations and anesthesia
• Intake and output chart
• Reports of physiotherapy ,occupational therapy
• Instruction book
33. Cont….
• Admission and discharge record
• Census record
• Call book
• Complaint book
• Indent book
• Drugs maintenance register
• Death register
• Movement register
• Round register
34. Nurse’s record
• Nurse’s assessment sheet
• Change of shift record
• Standardized care plan
• Nurse’s report book
• Nurse’s progress notes
• Treatment chart
• Graphic sheet
35. Student records
• Application forms and
other reports
• Admission register
• A cumulative health
record
• Class attendance and
leave record
• Clinical and field
experience , student
rotation
• Internal assessment
register- for both theory
and practical
• Mark list
• Records of extra-
curricular activities
• Practical record book
• Cumulative student
record
• Student evaluation
36. Staff records
• Application
• Copy of letter of
appointment
• Job description /
functions
• Periodic evaluation or
progress report
• Leave record
• Health record
Records of the staff member’s
– Educational qualification
– Previous experience
– Other short term educational
courses attended membership
in professional societies and
activities
– Contribution of articles to
journals
– Holding office in organization
– Participation in
seminars,conference etc.
updater every year
37. Academic /administrative records
• Philosophy, purpose and curriculum
• Course content and course plan record for each
subject
• Record of academic requirement
• Rotation plans for each academic year
• Record of committees
• Record of the stocks
• Affiliation records
• Records of educational programmes organized for
teaching faculty and students
38. Cont…
• Annual reports
• Written policies
• Statistical reports
• Statement of budget proposal and allotment
• Inspection/accredition record
• Photograph/video/paper cuttings of important
events
• Computerized records
• Copy of brochure
41. Factual
• A factual record contains descriptive, objective information
about what a nurse sees, hears, feels, and smells.
• Avoid vague terms such as appears, seems, or apparently
because these words suggest that you are stating an
opinion, do not accurately communicate facts.
• Objective documentation includes observations of a
patient’s behaviors.
• For example, instead of documenting “the patient seems
anxious,” provide objective signs of anxiety and document
“the patient’s pulse rate is elevated at 110 beats/min,
respiratory rate is slightly labored at 22 breaths/min, and
the patient reports increased restlessness.”
42. • The only subjective data included in the
record are what the patient says.
• When recording subjective data, document
the patient’s exact words within quotation
marks whenever possible.
43. • Date and Time
• Document the date and time of each recording.
• This is essential not only for legal reasons but
also for client safety.
• Record the time in the conventional manner
(e.g., 9:00 AM or 3:15 PM) or according to the
24-hour clock (military clock), which avoids
confusion about whether a time was AM or PM
44. • Timing
• Follow the agency’s policy about the frequency of
documenting, and adjust the frequency as a
client’s condition indicates.
• for example, a client whose blood pressure is
changing requires more frequent documentation
than a client whose blood pressure is constant.
• As a rule, documenting should be done as soon
as possible after an assessment or intervention.
• No recording should be done before providing
nursing care
45. • Legibility
• All entries must be legible and easy to read to
prevent interpretation errors.
• Hand printing or easily understood
handwriting is usually permissible.
46. • Permanence
• All entries on the client’s record are made in
dark ink so that the record is permanent and
changes can be identified.
• Dark ink reproduces well in duplication
processes.
• Follow the agency’s policies about the type of
pen and ink used for recording.
47. • Accepted Terminology
• People in the 21st century are often in a hurry and
use abbreviations when texting .
• Even though using abbreviations is convenient,
medical abbreviations have been responsible for
serious errors and deaths .
• Use only the standard and recognized abbreviations.
• Ambiguity occurs when an abbreviation can stand
for more than one term leading to misinterpretation.
• For example CP stand for chest pain, cerebral palsy,
cleft palate, creatine phosphate, and chickenpox
48. • Correct Spelling
• Use correct spelling while documenting.
• Correct spelling is essential for accuracy in
recording. Avoid spelling mistakes
• If unsure how to spell a word, look it up in a
dictionary or other resource .
• Two obsolutely different medications may have
similar spellings; for example, Fosamax and
Flomax
49. • Signature
• Each recording on the nursing notes is signed
by the nurse making it.
• The signature includes the name and title; for
example, “M.S. REDDY, RN”
• With computerized charting, each nurse has
his or her own password, which allows the
documentation to be identified.
50. • Accuracy
• The client’s name and identifying information
should be stamped or written on each page of
the clinical record.
• Before making any entry, check that it is the
correct chart.
• Do not identify charts by room number only;
check the client’s name.
• Special care is needed when caring for clients
with the same name.
51. • When a recording mistake is made, draw a
single line through it to identify it as erroneous
with your initials or name above or near the
line (depending on agency policy).
• Do not erase, blot out, or use correction fluid.
• The original entry must remain visible.
• When using computerized charting, the nurse
needs to be aware of the agency’s policy and
process for correcting documentation mistakes.
52. • Write on every line but never between lines. If
a blank appears in a notation, draw a line
through the blank space so that no additional
information can be recorded at any other time
or by any other person, and sign the notation
53. • Sequence
• Document events in the order in which they
occur;
• for example, record assessments, then the
nursing interventions, and then the client’s
responses.
54. • Appropriateness
• Record only information that pertains to the
client’s health problems and care.
• Any other personal information that the client
conveys is inappropriate for the record.
• Recording irrelevant information may be
considered an invasion of the client’s privacy .
55. • Completeness
• Not all data that a nurse obtains about a client can be
recorded.
• However, the information that is recorded needs to
be complete and helpful to the client and health care
professionals.
• Nurses’ notes need to reflect the nursing process.
• Record all assessments, dependent and independent
nursing interventions, client problems, client
comments and responses to interventions and tests,
progress toward goals, and communication with
other members of the health team.
56. • Conciseness
• Recordings need to be brief as well as
complete to save time in communication.
• Repeated usage of the client’s name and the
word client are omitted.
57. • Legal Prudence
• Accurate, complete documentation should give
legal protection to the nurse, the client’s other
caregivers, the health care facility, and the client.
• Admissible in court as a legal document, the
clinical record provides proof of the quality of care
given to a client.
• For the best legal protection, the nurse should not
only adhere to professional standards of nursing
care but also follow agency policy and procedures
for intervention and documentation in all
situations—especially high-risk situations.
59. Methods of recording
• There are several documentation systems for
recording patient data.
• Regardless whether documentation is entered
electronically or on paper, each health care
agency selects a documentation system that
reflects its philosophy of nursing.
60. Methods (styles) of Recording :
• Narrative Charting
• Source-Oriented Charting
• Problem-Oriented Charting
• PIE Charting
• Focus Charting
• Charting by Exception (CBE)
• Computerized Documentation
• Case Management with Critical Paths
61. Narrative Charting
– Describes the client’s status, interventions and
treatments; response to treatments is in story
format.
– Narrative charting is now being replaced by
other formats because of
• Time consuming writing
• Difficulty in retrieving the data
• Disorganization in the flow of care
62. Source-Oriented Charting
– Narrative recording by each member (source)
of the health care team on separate records.
– For example the admission department has an
admission sheet, nurses use the nurses’ notes,
physicians have a physician notes, etc….
63. Problem-Oriented Charting
– Uses a structured, logical format called S.O.A.P.
• S: subjective data
• O: objective data
• A: assessment (conclusion stated in a form of
nursing diagnoses or client problems)
• P: plan
64. Recently S.O.A.P. format is modified as
S.O.A.P.I.E.R for better reflecting the nursing
process
• S: subjective data
• O: objective data
• A: assessment (conclusion stated in a form of
nursing
diagnoses or client problems)
• P: plan
.I – intervention (specific interventions implemented)
.E – evaluation. Pt response to interventions.
.R – revision. Changes in treatment.
65. PIE Charting
– P: Problem statement
– I: Intervention
– E: Evaluation
• The key components of the system are assessment flow
sheets and nurse’s progress notes with plan of care.
• This system incorporates ongoing plan of care into the
daily documentation
• The PIE notes are numbered or labelled according to the
client’s problems.
• Resolved problems are dropped from daily documentation
after the nurses review, continuing problems re
documented daily.
66. Example:
– P: Patient reports pain at surgical incision as
7/10 on 0 to 10 scale
– I : Given morphine 1mg IV at 23:35.
– E : Patient reports pain as 1/10 at 23:55.
67. Focus Charting
– A method of identifying and organizing the narrative
documentation of all client concerns.
– Uses a columnar format within the progress notes to
distinguish the entry from other recordings in the
narrative
notes (Date & Time, Focus, Progress note)
– The progress notes are organized into: Data (D), Action
(A),
Response (R).
68. Date & Time Focus: Progress notes:
09.june.2015 Acute pain related
to
surgical incision
D: Patient reports
pain as
7/10 on 0 to 10
scale
A: Given morphine
1mg IV
at 23.35.
R: Patient reports
pain as
1/10 at 23.55
69. Charting by Exception (CBE)
– The nurse documents only deviations from pre-established
norms (document only abnormal or significant findings).
– Avoids lengthy, repetitive notes
• To enable the identification of trends in clients status
• Key elements required for CBE are
• Practice setting documentation policies and protocols
• Assessment norms, standards of care
• Individualized care plans
• Unique flow sheets
• Bedside accessibility of documentation forms it is not
acceptable to use documentation by exception unless
these exist
70. Computerized Documentation
– Increases the quality of documentation and
save
time.
– Increases legibility and accuracy.
– Facilitates statistical analysis of data.
71. Case Management Process
– A methodology for organizing client care through an
illness, using a critical pathway/ standardized care
plan.
– A critical pathway is a multidisciplinary plan or tool
that specifies assessments, interventions, treatments
and outcomes of health related problems a cross a
time line.
72. CARE OF RECORDS
The records could be arranged:
– Alphabetically
– Numerically
– Geographically and
– With index cards
73. • Keep under safe custody of nurses.
• No individual sheet should be separated.
• Not accessible to patients and visitors.
• Strangers is not permitted to read records.
• Records are not handed over to the legal
advisors without written permission of the
administration.
• Handed carefully, not destroyed.
NURSES RESPONSIBILITY FOR
RECORD KEEPING AND REPORTING
73R S MEHTA, MSND
74. cont..
• Identified with bio-data of the patients
such as name , age, admission number,
diagnosis, etc. (Legal Issues?)
• Never sent outside of the hospital without
the written administrative permission.
74R S MEHTA, MSND
75. COMMON RECORD KEEPING FORMS
• Admission nursing history form
• Flow sheets and graphic records
• Client care summary or kardex
• Acuity records
• Standardized care plan
• Discharge summary forms
76. Flow of Medical Record :-
The flow chart of inpatient Medical Record is as under :-
Central Admission
Office
Wards
Medical Record Department
1. Assembling
2. ADMN. &
Discharge
analysis
3. Storage Area
Afetr completion of
Reccords
Hospital statistics prepared
Monthly/Yearly
Medical Record is filled for perusal of
Patients/claims/research purposes.
77. Computerized documentation
• The computerized client records provide the
health care agencies to develop policies and
procedures to ensure the privacy and
confidentiality of client information that is stored
in computers
• Computer facilitates:
– Speed in communication accuracy in information
– Capability of information storage
– Data retrieval
– Data revision
78. Advantages of CD
• It enhances systemic
approach to client care
through standardized
protocols, teaching
documents
• It facilitates fast
communication
• It is cost effective
• Increases quality of
documentation
• Saves documentation
time by avoiding
duplication of effort
• Increases legibility and
accuracy
• It enhances statistically
analysis of data
• Provides access to client’s
other data such as
laboratory results
• Enhances coordination
among health team
members as information
is quickly conveyed
79. Disadvantages
• Costly installation of computer software
• Problem in protecting client’s confidentiality,
as in hospital everyone has access to
computer recording
• Transition to computerized documentation
presents both opportunities and challenges to
nurses and practitioners.
80. • Computer application in nursing douments
• Computer assisted nursing care
• It connects nurses station to each other and to all
departments by means of video display terminals
and printer hooked into central computer
• The existing and potential application fall into five
groups
– Storage and retrieval of clinical and statistical data
– Educational material
– Patient care plan
– Care audit
– Research
81. • Computer and nursing diagnosis
Computer can generate a list of possible
diagnosis for a patient with certain signs and
symptoms or it may enable the nurse to retrieve
and review a patient’s records according to the
nursing diagnosis
• Computer in nursing documentation
Nursing assessments, client’s care plans,
medication administration records, nursing
notes and discharge plans are some of the forms
of nursing documentation that are
computerized.
82. • Computer in nursing administration
Computer are useful tools of nurse
administrators. Can be used to assign nursing staff
based on severity of illness and needs of the patient
Helps the nursing administrators to prepare
and report letters, create budgets and maintain
personnel records and making lists
• Computer in nursing research
Save time, can increase the scope of the
search and the number of the data base that can be
searched
84. Reporting
• Reporting is the verbal or written communication
of data regarding the client’s health status and
needs.
• It facilitates clinical decision making, continuity of
care and co-ordination among health team
members
• The reports used in hospital setting usually are
• Change-of-shift reports
• Transfer reports
• Incident reports
85. Change - of - shift reports
• In this type of report, on duty nurse
summarize information about assigned client,
work to the nurse working for next shift
• It also known as end of shift report
• The purpose is to provide continuity of care
among nurses who are caring for a client
86. • Points to be kept in mind while giving such reports:
• Provide only essential background information
about client
• Identify client’s nursing diagnosis or health care
problems and other related causes
• Describe objective measurements or observations
about client condition and response to health
problems
• Share significant information about family
members, as it relates to client’s problems do not
make any assumptions about relationship between
family members
87. • Continuously review ongoing discharge plan.
• Relay to staff significant changes in the way
therapies are given, do not describe basic
steps of a procedure
• Describe instruction given in teaching plan
and client’s response.
• 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 oncoming staff
must attend
88. Example
• Mr. x in bed 12, orthopedic ward, a 30 yr client
of Dr.Y is scheduled for a amputation of right
lower limb this morning. He had gangrene
fromation. He was admitted last night. This is
his first experience with surgery
• Assessment :
Mr.x expressed difficulty falling asleep last
night. He asked several questions about surgery.
• Nursing diagnosis :
• Anxiety related to inexperience with surgery
• Risk for body image disturbance
89. • Teaching plan:
He asked relavant questions about surger.
Nurse on evening duty explained
postoperativeroutines. I reinforced information
with client early in night. He stated that he felt
less anxious, also observed so through vital sign
monitoring
• Treatments:
Client received tab diazepam 5mg po at 10
p.m psychological support was given . Client was
awake at 6 a.m and stated he slept well
90. • Family information:
Client wife accompanied him last evening until
the end of visiting hours. She is in room this morning
• Discharge plan:
Mr. x is a very active and responsible person at
home. He is a famer by occupation. Mr.x is
concerned about how he might react to amputation.
I suggest making a referral to the rehabilitation
consultant early
• Priority needs:
Mr. x is relaxing in his room. Written consent
for surgery has been signed. All preoperative
procedures have been completed except for his
preoperative medication which is due on call to the
operating room
91. Transfer report
• Such reporting is done incase client is
transferred form one ward to another ward to
receive different level of care
• Eg: client transferred from recovery room to
medicine ward when the client no longer
require such intensive services
92. • While giving such reports, the nurse should
include the following
• Client’s name,age,primary doctor and medical
diagnosis
• Summary of medical progress up-to the time of
transfer
• Current health status- physical and psychosocial
• Current nursing diagnosis or problems and care
plans
• Any critical assessment or interventions to be
completed shortly
• Needs for any special equipment etc.
93. Incident reports
• Incident reports are used to document any
unusual occurrence or accident in the delivery of
client care( client falls, medication errors)
• An incident is any event that is not consistant
with routine operation of a health care unit or
routine care of client
• 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
94. • The nurse describe in concise form what happens
specifically objective terms,
• The nurse dose not interpret or attempt to explain
the cause of the incidence
• The nurse describes objectively the client’s
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.
95. Minimizing legal liabilities through
effective record keeping
• Now a days public is very much aware of their rights.
• Every client expects best quality care in hospitals
• Documents reflect care provides, so in order to
minimize legal liabilities, documents must be effective
enough by having following characteristics
• Factual
• Accurate
• Complete
• Legible
• Logically organized
96. • Client’s identification information must be written on each
page of the client’s record
• While making entry on record, it must be started with
complete date,month,year
• In case of wrong entry, never throw the records. Incorrect
information should be crossed out while retaining the
original information .
• Nurse should never edit or delete the documentation done
by other personnel
• At the end of nursing notes , line can be drawn , so that no
else can add documentation
• Documents must be signed by the nurse at the end of entry
• Never leave empty space between entries as someone else
can add
97. • Content of documentation includes assessment , nursing
action, indication as well as client’s reaction. Incase any
intervention is omitted , must right the explanation
• While documenting , follow the hospital policies
• While receiving verbal order, nurse must document the
order,name,date,time of receiving order. It must be signed
by physician within 24 hrs in critical settings
• Incident report should not be described in nursing
documentation
• As client has right to inform, every procedure must be
explained to client. Written consent should be taken
before operations
• The two important laws relate to health records
– Data protection act 1998
– Human rights act 1998
• Nurses can be protected from laws if they follow policies
and procedures while documenting
