Documenting and reporting

Pages 104-111

Prepared by: Dr.Reem A.Jarrad

Why communication between staff
?is important

Because it enhances quality and 

continuity of clients care

Definitions of nursing communication
methods

Discussion: is an informal oral -1 

consideration of a subject by two or

more health professionals to identify
a problem or to develop strategies
.to resolve one
Definitions of nursing communication
methods

Report: is oral, written or -2 

computer based communication

intended to convey information to
.others
Definitions of nursing communication
methods

record : is a written or computer -3 

based documentation( charting or

.recording)
What are the purposes for using client
?records
Communication -1 

Planning client care -2 

Auditing health agencies ( quality assurance) -3 

Research -4 

Education -5 

Legal documentation -6 

Health care analysis ( SWOT= strengths,-7 

weaknesses , opportunities, and threats)

Documentation Systems

Source oriented record -1 

Problem oriented medical record -2 

Pie ( problems, interventions and -3 

evaluation)
Focus Charting -4 

Computerized documentation -5 

Note : practice tips for documentation on the bottom of 

.)page 108
General Guidelines for recording

Date and time -1 

Frequency of documenting according to policy and -2 

client condition

Legibility ( easy to read..) -3 

Permanence ( dark ink) -4 

Accepted Terminology -5 

Correct spelling -6 
General Guidelines for recording

Signature -7 

Accuracy ( how to manage wrong entry?) -8 

Sequence (order of occurrence) -9 

Appropriateness ( relevant client data only) -10 

Conciseness ( Brief recording)-11 

Legal caution( look nursing note page 107, right -12 

upper border, directly above word reporting)

Reporting

:Definition 

to communicate specific information 

to a person or group of people,

.whether oral or written
Examples for Reporting

Change of Shift Reports -1 

Telephone reports -2 

Care Plan Conference -3 

Nursing Rounds -4 

)Pages 107-108( 
Good luck with first exam
Which will be on the 28-10-2014 - 

The same time and place of the 

.lecture

Two value- ethics lectures will - 

remain after the exam, and will be
included in the second exam

Your Tutor