Assignment: Documenting and Reporting

What is documentation? *

Documentation - Is an integral part of nursing practice and professional of nursing care rather
than something that takes away from patients care.

What are the purposes of client's record?

1. COMMUNICATION - Serves as vehicle by which different health professionals who interact
with a client communicate with each other. This prevents fragmentation, repetition , and delays
in clients care.
2. PLANNING CLIENT CARE - Each health care professional uses data from the client's record to
plan for that client.
3. AUDITING HEALTH AGENCIES - An audit is a review of clients record for quality assurance
purposes. Accrediting agencies such as The Joint Commission may review clients records to
determine if a particular health agency is meeting its stated standards.
4. RESEARCH - The information contained in record can be valuable source of data for research.
The treatment plans for a number of clients with the same health problems can yield
information helpful I treating other client.
5. EDUCATION - Students in health discipline often use clients records as educational tool.
6. REIMBURSEMENT - Documentation also help a facility receive a reimbursement from the
federal government. For a facility to obtain payment through Medicare, the client's medical
record must contain the correct diagnosis related group (DRG) codes and reveal that
appropriate care has given.
7. LEGAL DOCUMENTATION - The client record is a legal document and is usually admissible
court as evidence.
8. HEALTH CARE ANALYSIS - Information from records may assist health care planners to
identify agency needs, such as over utilized and underutilized hospital services.

What are the types of documentation systems?

SOURCE ORIENTED RECORD - It is a traditional client record, each person or department makes
notation in separate section or section of client chart.
NARRATIVE CHARTING is a traditional part of the source of the source oriented records. it
consist of written notes that include routine care, normal findings, and clients problem.
PROBLEM - ORIENTED MEDICAL RECORD - Established by Lawrence Weed in the 1960'S
The data are arranged according to the problems the client has rather than the source of the
information. Members of the health care team contribute the problem list, plan of care, and
progress notes. Plans for each active or potential problem are drawn up, and progress notes are
recorded for each problem.
Four basic components of POMR:
DATA BASE - Consist of all information known about the client when the client first enters the
health care agency.
PROBLEM LIST - is derive from the data base. It is usually kept at the front of the chart and
serves as an index to the numbered entries in the progress notes.
PLAN OF CARE - The initial list of orders or plan of care in made with reference to the active
problems. Care plans are generated by the individual who list the problems.
PROGRESS NOTES - Is a chart mad by all health professionals involved in clients care; they all
use the same type of sheet for notes.
PIE (Problems, interventions, and evaluation)
- PIE documentation model groups information into three categories. first is the problem
statement that is labeled "P' and referred to the number (e.g., P #5). second is interventions
employed to manage the problem are labeled "I" and numbers according to the problem (e.g.,
I #5). lastly is evaluation of the effectiveness of the interventions is also labeled and numbered
according to the problem (e.g., E #5).
The flow sheet uses specific assessment criteria in particular format, such as human needs or
functional health patterns .The parameters for a flow sheet can vary from minutes to months.
Focus charting - is intended to make the client and client concerns and strengths the focus of
care. Three columns for recording are usually used: date and time , focus, and progress notes.
The progress notes are organized into (D) data, (A) action, and (R) response referred to as DAR

What are the guidelines for recording?

1. TIME AND DATE - This is essential not only for legal reasons but also for client's safety.
Record the time in the conventional manner or according to the 24- hour clock to avoid
confusion wether the time was AM or PM.
2. TIMING - Follow the agencies policy about the frequency of the documenting and adjust the
frequency as a client's condition indicates. As rule, documenting should be done as soon as
possible after an assessment or intervention. No recording should be done before providing
nursing care.
3. LEGIBILITY - All entries should must be legible and easy to read to prevent interpretation
errors . Hand printing or easily understood handwriting is usually permissible . Follow the
agency's policy about handwritten recording.
4. PERMANENCE - All entries on the clients record are made in the dark ink so that the record is
permanent mad changes can be identified. Dark ink reproduce well on microfilm and in
duplication processes. Follow the agency's policies about the type of pen and ink used for
recording in regards in EHRs, changes are made in accordance with the software guidelines. It
is important for the nurse to understand the policies and procedures of the health care
institution regarding documentation.
5. ACCEPTED TERMINOLOGIES - Abbreviations are used because they are short, convenient, and
easy to use. Use only commonly accepted abbreviation or symbols, and terms, that are
specified by the agency. Many health care facilities supply an approved list of abbreviations
and symbol to avoid confusion.
6. CORRECT SPELLING - It is essential for accuracy in recording. If unsure how to spell a word,
look it up in a dictionary or other resource book.
7. LEGAL PRUDENCE- accurate complete documentation should give legal protection to the
nurse, he clients other caregivers, the health care facility, and the client.
8. ACCURACY - The clients name and identifying information should be stamped or written on
each page of the clinical record . Before making an entry check that the chart is the correct
one . Do not identify chart by noon number only, check the client's name. Special care is
needed when caring for the clients with the same last name.
9. SEQUENCE - Document events in the order in which they occur, for example record
assessment , then the nursing interventions, and then the clients responses. Update or delete
problem as needed.
10. APPROPRIATENESS - Record only information that pertains to clients health problems and
care. Any other personal information that the client convey is inappropriate for the record.
Recording irrelevant information maybe considered invasion of the clients privacy and / or
libelous .
11. COMPLETENESS - Not all the data that the nurse obtains about client can be recorded.
However , the information that is recorded needs to be complete and helpful to the client and
health care professionals.

What is reporting?
Reporting - takes place when two or more people share information about client care, either
face to face or by the telephone

What are types of reporting and its purposes? 

CHANGE OF SHIFT REPORTS - Incomplete handoff communication is associated with sentinel
events that will result in adverse health care outcomes or death. The handoff communication or
change of shift report is given to all nurses on the next shift.
TELEPHONE REPORTS - the nurse receiving the telephone repots should document the date and
time, the name of the person giving the information, and the subject of the information
received and sign the notation.
TELEPHONE ORDERS - primary care provider order a therapy for a client by telephone
CARE PLAN CONFERENCE - a care plan conference is a meeting of group of nurses to discuss
possible solutions to certain problems of a client, such as in ability to cope with an event or lack
of progress towards goal attainment.
NURSING ROUNDS - are procedures in which two or more nurses visit selected clients at each
clients bed side to obtain information that will help plan of nursing care, provide clients the
opportunity to discuss their care, evaluate the nursing care the client has received.

PURPOSE OF REPORTING
- To communicate specific information to a person are group of people.