DOCUMENTATION

Documentation is any written or electronically generated information about a client that describes the care or
service provided to the client. Health records may be paper documents or electronic documents such as electronic
medical records, fax, images etc.
TYPES OF DOCUMENTATION SYSTEMS
1. Paper based documentation system
2. Electronic documentation: medical record in digital format
RECORDS

Records are formally legal, administrative tools that permanently document information relevant to direct or
indirect patient care.

Records are highly confidential, legal documents by means of which physicians, nurses, social workers and
health team members communicate about patients.

PURPOSES OF RECORDS

It provides an accurate and detailed account of treatments and care given to the patient.

They evaluate quality patient care

They can be used as a reference material for research

Records are tools of communication among the health care team members

Records also have a legal value. The records safeguard the patients, nurses, doctors and the hospital. It serves
as evidence that the patient care is intelligently managed.

They help the nursing and medical students in their clinical experience and provide data for care studies.

It serves as a follow up of the course of the disease and future care

A record of illness and treatment saves duplication of work in the future care especially when the patient is
transferred from one department to another or from one institution to another or when an attending physician is
transferred or other personnel takes charge.

The patients record, registers and reports furnish the vital statistics and give information needed to evaluate
the health care services rendered by the hospital to the community.

Data taken from the patients record points out the health problems of the country and it also provides a
baseline in which local, state, national and international health services can be planned.

Auditing health agencies

TYPES OF RECORDS

Report book

Treatment book

Duty roster for staff

Stock register

Admission and discharge book

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Complaint book for maintenance and repairs

Indent register

Reports of laboratory examinations

Diet register

Graphic charts of temperature, pulse and respiration

Consent form for operations and anesthesia

Records of anesthesia, physiotherapy, occupational therapy and other special treatments

Physicians order sheets

REPORTS

A report consists of oral or written exchanges of information shared between members in the health care team.

A report is a system of communication aimed at transferring essential information necessary for safe and
holistic patient care.

PURPOSES OF REPORTS

To communicate progress of the patients health status to all nurses in different shifts

To prepare staff members for their days work

To ensure that all the staff members have the same information

To maintain continuity of care from one shift to another

To illustrate progress in reaching goals

To coordinate care among various health care personnel

To promote accuracy in the provision of quality care and prevent errors

To effectively manage time and avoid duplication or overlapping of activities

TYPES OF REPORTS

Change of shift reports

Telephone reports

Telephone orders

Transfer report

Incident reports

Reports among the members of the health team

Each member of the nursing team gives a detailed report to the team leader/ staff in- charge at the end of the shift.
This is about the patients, their condition, no. of patients, and any specific reports. A report is given when the
responsibility for patient care is turned over from one person to another

Reports between the head nurse and her assistant

Reports between the head nurse and the nursing superintendent

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The day, evening and night reports are sent to the nursing superintendent at regular intervals. This includes the
reports of all seriously ill patients, the newly admitted patients, patients who had surgery, patients who had
accidents, census etc. the report may also contain the problems that are met with the patient care. E.g. inadequate
supply of articles.

Reports to the physician

The nurses provide report of any unusual changes in the patients condition like medication side effects, results of
any investigations etc.

Reports on accidents, mistakes and complaints

A detailed report on mistakes, accidents and complaints is sent to the concerned authority such that such incidents
are prevented in the future and there is improvement in patient care.

NURSING ROUNDS/VISITS
Nursing rounds are conducted by the head nurse/ nurse teacher with her staff members/ students for a clear
understanding of the disease and the effect of nursing care for each patient.
PURPOSE OF NURSING ROUNDS/VISITS

To assess the physical and mental condition of the patients and the progress made each day.

To observe the work of staff

To make specific observations of patients e.g. wounds, drainage, bleeding etc.

To introduce patients to the staff members i.e. the patients history, treatment and all the medical aspects of his
care.

To formulate a plan of action for care of patients

To evaluate the results of treatment and patient satisfaction

To ensure that safety measures are employed for patients and personnel

To orient the staff nurse/ nursing students towards the health status of their patients

To teach nursing students and hospital staff regarding specific conditions

To initiate any modifications in nursing action

To ensure the safety and working condition of the equipments kept in the patients bedside

ADVANTAGES OF NURSING ROUNDS/VISITS

They offer a real life learning situation to both student nurses as well as staff

It helps in the evaluation of nursing activity

They help in orienting a staff nurse/ student nurse to the patient

The hurdles faced by nurse in implementing treatment can be resolved

To evaluate the nursing care and level of satisfaction among patients

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DISADVANTAGES OF NURSING ROUNDS/VISITS

The confidentiality of the patient is hampered

Distractions are present in the ward

An unprepared nursing round has little teaching learning value

It is not effective if the group is large

It may evoke undue anxiety in the patient when his/her case in discussed.

NURSING MANUALS
It is the compilation of all the rules or guidelines concerning the procedures or management of identified problems
which available for reference. The contents of the manuals, particularly in relation to the specific procedures are
more acceptable if compiled following a group discussion.

ADVANTAGES

They specify the purpose for which the procedure is to be used, the equipment needed, the sequence of steps in
the procedure and the precautions to be observed.

The standards of performance are ensured

Helps in the provision of safe and effective care with available resources and personnel

DISADVANTAGES

If the manuals are not revised periodically, faulty and old practices may continue

NURSING PROTOCOLS
Protocols are written instructions for caregivers to follow when individuals have specific or frequent problems
from a health concern that usually has a predictable outcome. Protocols give guidance to caregivers on signs and
symptoms to looks for, when and how to intervene and who to notify.
Protocols are sometimes confused with procedures. Procedures are task oriented. They provide step-by-step
instructions on how to do a task. For example: how to administer a gastrostomy feeding or how to empty a
Foley catheter bag.
Standing orders are specific instruction regarding treatment for condition that nurses and other health workers may
encounter in home, school and industries where a doctor is not readily available. The standing order are intended
to provide treatment only in emergencies and temporarily in the absence of a doctor, they should be limited.
PURPOSE

To promote health services in community

To provide temporary treatment in the absence of a doctor

To deliver care at home, school, community

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To meet emergency situation in rural area

TYPES OF STANDING ORDER

1. Institutional standing orders
They are kept keeping in view the available resources, staff position and the objectives of a medical institution
or hospital. E.g. Standing orders of primary health centers can be different from those of district hospitals.
2. Specific standing order
These orders are meant for trained medical personnel, mainly the nurses. Technical knowledge and specific
skills are required to implement these orders. E.g. giving care at home, injections, oxygen therapy etc.
3. General standing orders
Owing to a large population, vast geographical area and the shortage of resources, some standing orders are
used to propagate health care messages to the masses. E.g. preventive measures against AIDS etc.

ADVANTAGES OF STANDING ORDERS

They help to strengthen the primary services in the community

They help to decentralize the health responsibilities

They provide a feeling of confidence and responsibility in the nursing staff and other health workers

They enhances the quality and activity of health services

Community standing orders provides timely treatment during emergencies

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