St.

Paul College of Ilocos Sur

(Member, St. Paul University System)
St. Paul Avenue, 2727 Bantay, Ilocos Sur

NCM 101: Health Assessment

Module 4

DOCUMENTATION AND REPORTING

Melanio P. Rojas Jr, MAN

Clinical Instructor

2024

Module No. 4
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 DOCUMENTATION AND REPORTING

Learning Objectives:

After completing this module, the students will be able to:

1. Discuss the purpose of client’s record.

2. Identify the characteristics of recording and reporting.

3. Create a sample FDAR.

4. Enumerate types of record.

St. Paul College of Ilocos Sur

(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

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 DEPARTMENT OF NURSING

PRE-LEARNING ACTIVITY

PRE-TEST EXAMINATION: MODULE 4

NCM 101: Health Assessment

Second Semester A.Y. 2023-2024

Melanio P. Rojas Jr. MAN

Lec
(Clinical Instructor)

Name: _______________________________ Score: ___________________

Course/Year: __________________________ Date: ____________________

I. Give a specific scenario or situation regarding documentation given below.

Documentation Rationale Specific situation

1. Chart only what you personally
have done, observed, heard,
smelled or felt.
2. Medication should be charted
immediately after given.
3. Chart objective facts, not your
interpretations or opinions.
4. Use only those abbreviations and
symbols approved by the
institutions spell correctly; use
proper grammar
5. Only the health personnel who
participate in the care of the client
are allowed to read the chart

DOCUMENTING AND REPORTING

Documentation serves as permanent record of client information and care.

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Reporting takes place when two or more people share information about client care, either face
to face or by the telephone.

Purposes of client’s record/chart

1. Communication. Provides efficient and effective method of sharing information. It

allows to convey meaningful data about the client
2. Legal documentation. It is admissible as evidence in a court of law
3. Research. Provides valuable health-related data for research
4. Statistics. Provides statistical information that can be utilized for planning people’s
future needs
5. Education. Serves as an educational tool for students in health discipline
6. Audit and quality assurance. Monitors the quality of care received by the client and
the competence of health care givers.
7. Planning client care. Provides data which the entire health team uses to plan care for
the client.
8. Reimbursement. Provides the basis for decisions regarding care to be provided and
subsequent reimbursement to the agency, to cover health-related expenses.

TYPES OF RECORDS

A. Source oriented medical record (traditional client record)

- Each person or department makes notation in a separate section/s of the client’s chart

FIVE BASIC COMPONENTS OF THE TRADITIONAL CLIENT RECORD

1. Admission
2. Physician’s order sheet
3. Medical History
4. Nurse’s notes
5. Special records and reports (referrals, X-ray reports, laboratory, findings, report of
surgery, anesthesia record, flow sheets, vital signs I and O and medications).

B. PROBLEM –ORIENTED MEDICAL RECORD (POMR OR POR)

 Data about the client are recorded and arranged according to the source of the
information
 The record integrates all data about the problem, gathered by the members of the health
team.

FOUR BASIC COMPONENTS OF POMR/POR

1. Database. Contains all the initial information about the client.

2. Problem list contains all the aspect of the person’s life requiring health care.

3. Initial list of orders or care plans.

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4. Progress notes

 Nurse’s or narrative notes (SOAPIE and FDAR FORMAT)

 Subjective data Focus
 Objective data Data
 Assessment Action
 Planning Response
 Intervention
 Evaluation
 Flow sheets ( data are monitored)
 Discharges notes or referral summaries

KARDEX

 Provides a concise method of organizing and recording data about a client, making
information readily accessible to all members of the health team.
 It is a series of flip card usually kept in portable file.
 It is a way to ensure continuity of care from one shift to another and from one day to the
next.
 It is a tool for change of shit report. But endorsement is not simply reciting content of
kardex. The health care needs of the client is still primary basis for endorsement.
 Kardex usually includes the following data:
 Personal data (demographic data)
 Basic needs
 Allergies
 Diagnostic tests
 Daily nursing procedures
 Medications and intravenous (IV) therapy, blood transfusions
 Treatments like oxygen therapy, steam inhalation, suctioning, change of
dressings and mechanical ventilation.
 Entries are usually in pencil so that they can be changed as client’s condition changes.
This implies kardex is for planning and communication purposes only.

CHARACTERISTIC OF GOOD RECORDING

1. Brevity

 Entries are concise.

 Complete sentences are not required.
 Start each entry with a capital letter and end the entry with a period even if the entry is a
single word or phrase.

2. Use of ink/permanence

 Avoid felt pen or pencil for permanence of data, because the client’s chart can be used
as an evidence in a legal court.

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3. Accuracy

 Chart objective facts, not your interpretations or opinions.

 E.g.
 Correct: ate 50% of the food served
 Incorrect: ate with poor appetite
 Correct: refused medication
 Incorrect: uncooperative
 Correct: Seen crying
 Incorrect: depressed
 Place complaint of the client in quotation marks to indicate that it is his statement.
E.g. complained of “chest pain radiating down to the left arm.”
 Objective data are also to be charted.
E.g. skin cold and clammy, diaphoretic. Prefers to sit up. Vital signs taken as follows:
temperature= 37.6 Celsius, Pulse rate= 110/min RR= 26/min and BP=146/90 mmHg
 Describe behaviors rather than feelings to allow other health team members to
determine and treatment must be documented.

4. Appropriateness

 Only information that pertain to the client’s health problems and care are recorded.
 Any other personal information that is conveyed to the nurse is inappropriate for the
record.

5. Completeness and chronology/organization/sequence/timing

 Note should appear on each succeeding line.

 Continuous charting is done for each entry unless a time occurs. No need for a new line
for each new idea or entry.
 Date is entered in the date column on the first line of every pages of nurse’s notes and
whenever the date changes.
 Time is entered in the time column whenever a new time entry occurs.
 Avoid time changes in the text of nurse’s notes.
 Avoid double chart. If something appears on a particular sheet, it does not need to
appear on a particular nurse’s notes, unless there in an alteration from the normal. E.g.
body temperature.
 Avoid squeezing information into a space because you forgot to chart it earlier. Add the
information on the first available line. Write the time the even occurred, not the you
entered the information.

THE FOLLOWING INFORMATION SHOULD BE CHARTED:

 Physician’s visits.
 Times the patient leaves and returns to the unit, mode of transportation and destination.
 Medication should be charted immediately after given.

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  Treatment should be charted immediately after given.

6. USES OF STANDARD TERMINOLOGY

 Use only those abbreviations and symbols approved by the institutions spell correctly;
use proper grammar.

7. SIGNED

 Affix signature, place at the end of the charting, at the right-side hand margin of the
nurse’s notes.
 Sign each entry with your full name and status e.g., BSN/SN- student nurse and RN for
registered Nurse.
 Script, not printing is used for signature.

8. IN CASE OF ERROR

 Correct errors by drawing a single (horizontal) line through the error.

 Write the word error, above the line, then sign your signature.
 No ink eradication, erasures use of occlusive materials.
 E.g. ERROR MPR
Pulse 180 beats/min 108 beats/min

9. CONFIDENTIALITY

 Only the health personnel who participate in the care of the client are allowed to read the
chart

10. LEGAL AWARENESS

 Chart only what you personally have done, observed, heard, smelled or felt
 Do not discard any part of the client’s record

11. LEGIBLE

 Writing must be clear and easily read by others.

 If writing is not legible, then print.

12. DO NOT USE THE WORD “PATIENT OR PT in chart; the chart belongs to the patient. All
information in the chart pertain to the patient.

13. A horizontal line drawn to fill up a partial line. This is to prevent other persons from adding
information in the nurse’s notes.

 E.g.------------------------------------------------------ Melanio P. Rojas Jr, RN

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 St. Paul College of Ilocos Sur
(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

DEPARTMENT OF NURSING

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 POST-LEARNING ACTIVITY

POST TEST EXAMINATION: MODULE 4

NCM 101: Health Assessment

Second Semester A.Y. 2022-2023

Melanio P. Rojas Jr. MAN

(Lec)
Clinical Instructor

Name: _______________________________ Score: ___________________

Course/Year: __________________________ Date: ____________________

I. Please create using the format FDAR by applying guidelines of documentation.

Situation: Covida de Mama is admitted to ISPH- Gabriela Silang General Hospital. Her chief
complaint is loss of appetite, lose weight of 10 pounds, body weakness and poor skin turgor.
She verbalize that “Awan ganas ko magan adu ngamin problemak iti pinagbiag ko.”

F-
D-
A-
R-

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