Recording & Reporting

Medical Records
Medical records are written collections of •
information about the person’s health , about
the care provided by health practitioners , the
client’s progress ,also called health records or
client records , the form of health records
depends on the policy of the agency may be
hard copies or computerized , the hard copy
.placed in a chart , files or records
 Computerized medical records is accessed by •
using password and selecting the desired form
from menu , so all personnel involved in a
client’s health care contribute to the medical
record by charting , recording or documenting
which is the process of entering information
on the health agency’s form
 : Uses Are
Permanent Account : medical record is a •
written , chronologic account of a person’s
illness or injury and the health care provided
from the onset of the problem through
discharge or death , the record or file maintain
for future reference , on admission previous
records are requested so that the client’s
. health history can be reviewed
Sharing Information : serve as communication •
or exchange information or sharing
information among health personnel so the
documentation serves as a way to inform
others about client’s health status and plan of
care , also prevent duplication of care reduce
the chance of error or omission , accurate and
timely is so important so the documentation
promote continuity of care
Quality Assurance : in order to maintain high •
level of care hospitals or health agencies use
medical records to promote quality
assurance , continuous quality improvement
or total quality improvement which uses for
internal agency self-assessment and
improvement , in all the purpose is to ensure
that the level of care reflects or exceeds
established standards
 Accreditation : the Joint Accreditation of •
Healthcare Organization , JCAHO is a private
association that has established criteria
reflecting high standards for institutional
health care so this association inspect health
care agencies to determine whether they
demonstrate evidence of quality care JCAHO
requires the following nursing documentation
evidence to justify accreditation (book pg 111)
 Reimbursement : the auditors or inspectors •
who examine client records survey medical
records to determine whether the care
provided meets established criteria for
reimbursement
Education & Research : the first education is •
the textbooks then medical records providing
the examine about specific disorders which
enhance learning and problem solving
 Also client records facilitate the research , •
here we need formal permission and
signature of the clients or family
Legal Evidence : and the information should •
be written clearly because any vague or
written not clear makes poor legal defense
 Client Access to Record
Before it was not allow that the client can see •
the medical records but around 2001, 2002 and
2003 by Medcom there was many institutions
have written policies that describe the guidelines
by which clients can access to their own medical
records the policies can range from complete we can
see the medical records or unrestricted depends on the
physician or hospital administration and the nurse must
follow the agency policy
 Types of Client Records
Source-Oriented Records : is a traditional type •
, this type contains separate forms on which
physician , nurses , dietitians , physical
therapist and other health care providers
make written entries toward the patient care ,
but the criticisms or disadvantage of this type
is difficult to demonstrate a unified
cooperative approach for resolving the client’s
problems among caregivers
 So it’s give the impression that each •
professional is working independently of the
others
Problem-Oriented Records : organized •
according to the client’s health problems , this
type contain : data base , the problem list , the
plan of care and the progress notes
 Here the information is compiled and •
arranged to emphasize goal-directed care , to
promote recording of appropriate information
and to facilitate communication among health
care professional
 Methods of Charting
Narrative Charting : is a style of •
documentation generally used in source-
oriented records involve written information
about the client and client care in chronologic
order , is time consuming to write and read ,
contain specific information that correlates
the client’s problems with care and progress ,
needs skillful person to write
 SOAP Charting : more likely used in problem- •
oriented record , S= Subjective data ,
O=objective data , A= analysis of the data and
P= plan of care , some agencies expanded SOAP
to SOAPIE or SOAPIER which is : intervention ,
Evaluation and Revision to the plan of care .
SOAP charting helps to demonstrate interdisciplinary
cooperation because everyone involved in the care of
the client makes entries in the location of the chart
 Focus Charting : consider holistic because its •
focus of the client’s strength and problem this
methods contain : Data , action & Response
called DAR (see figure pg 114)
PIE Charting : is a method of recording the •
client’s progress under the headings of
problem , Intervention & Evaluation so the PIE
style prompts the nurse to address specific
content in a charted progress note
 Charting by Exception : nurses chart only •
abnormal assessment findings or care deviates
from standards so this method not effective
because it’s provide access to abnormal finding
and does not describe normal routine
information
Computerized Charting : advantages pg 115 •
Disadvantages : Expensive , need training , •
electronic mal function
 Documenting Information
Using Abbreviations (see table pg 118) •
Indicating Documentation Time , date once , •
time every time we makes entries :
am,md,pm,mn

Note : Protective Health Information Concern •

USA
 Communication for Continuity &
Collaborative
A-Written Forms of Communication , the •
: examples for these are
Nursing Care Plans : is a written list of the -1 •
client’s problems , goals and nursing orders for
the client’s care , it promotes the prevention ,
reduction or resolution of health problems
(see figure 9-7) if this form is handwritten it
should be clear concise and legible
 Nursing Kardex : is a quick reference for-2 •
current information about the client care ,
usually the Kardex is kept in separate folder ,
Kardex has the following uses : See book pg
119
The information in the Kardex change •
frequently sometimes several times one day is
not permanent record so the nurse can write
information in pencil and erase
 Checklist : form of documentation in which-3 •
the nurse indicates check mark for the routine
performance care or preoperative checklist
Flowsheet : mostly uses for the Vital Signs-4 •
B-Interpersonal Communication : examples of •
: these forms are
Change of shift report : is discussion-1 •
between nursing at the end of the shift and the
person coming to duty it include a summary of
each client’s condition and current status of
care in order to maximize the efficiency of
change of shift reports nurses should do the
following : see pg 121
 Client Care assignment : is done at the-2 •
beginning of each shift , assignments are
posted , discussed with the team members or
written on a worksheet , assignment identifies
the clients for whom the staff person is
responsible and describe their care , also in
the assignment should written the meals and
break time
 Team Conference : used to exchange-3 •
information , topics may be concern about the
client problem , personnel conflicts , new
equipment or treatment methods or changes
in policies and procedures , team conferences
involves nursing staff , staff from other
departments involved in client care , physician
social workers , others depends on the
situation and condition
Usually one person organizes and directs the •
conference , responsibilities for certain
outcomes that result from the team
conference may be delegated to various staff
members who attend the meeting
Client Rounds : visit the client , first is used-4 •
as a means of learning because the client is a
witness to and often an active participate in
the interaction , second is a means of change
of shift which help in survey the client’s
condition and to determine the status of the
equipment used for care , if another client
share the room is preferable to avoid
communication
Or sometimes client has not authorized family •
member or friends who visiting to have access
to their health information
Telephone : used when it is difficult for-5 •
people to get together or when they must
communicate information quickly when uses
the telephone the nurse does the following :
see pg 123
 When notifying physician about a change in a •
client’s condition the nurse documents in the
client’s record the information reported and
instructions received , if the nurse believes
that the physician has not responded in a safe
manner to the information given , the nurse
notifies the nursing supervisor or the head of
the medical department