DOCUMENTING

and
REPORT ING

By
Abdulrazak bashir sani
RN, BNSc.
 OBJECTI VES:
At the end of the discussion, the students will be able
to:
1. Define documentation and reporting.
2. State the importance of documenting and reporting
to the nursing profession.
3. Use commonly used abbreviations correctly
4. Understand the purposes of a report.
5. Plan a report.
6. Understand the structure of a report.
7. Collect information for your report.
8. Organize your information.
9. Use an appropriate style of writing.
10. Present data effectively.
11. Understand how to lay out your information in an
appropriate way.
 INTRODUCTION
A shift-to-shift report should be given not only from the
Kardex but from the client care plan. There is no need to
review particular procedures for such activities as dressing
changes, when they are outlined on the care plan. A simple
statement to the effect that the procedure is listed on the
care plan is all that is necessary. This decreases both time
and repetition of information. To avoid confusion from
shift to shift, specific times for treatments and for activities
of daily living (ADLs) are indicated. For example, it is
noted on the care plan that the client prefers his bath before
8 AM to avoid having to ask him every day when he wants
his bath. This consistency promotes a feeling of confidence
in the nursing staff and alleviates fear
1. DAT 1. p.r.n.
2. o.u. 1. p.c.
3. b.i.d 2. a.c.
4. BP 3. q.i.d.
5. gtt. 4. k.s.s
6. h.s. 5. Stat
7. IM 6. T.i.d.
8. IV 7. q.15 mins.
9. p. 8. NGT
10. KVO 9. KUB
 DEFINITIONS
• DOCUMENTATION serves as a permanent record of
client information and care.
• REPORTING: Is the act of making a record of an
observation available for review.
• REPORT: the account, usually verbal and often tape-
recorded, that the nursing staff going off duty gives to the
oncoming staff in order to provide continuity care despite
the change in the staff. (Taber’s 23rd version) or
• It is a record of a drug reaction, illness, medical
emergency, or other health related statistics. (Taber’s 23rd
version) or
• It is a statement of the result of an investigation or of
any matter on which definite information is required.”
(Oxford English Dictionary)
 Cl ient’s Recor d

 Communication: provide efficient and effective

method of sharing information.
 Legal Documentation. It is admissible as evidence in
a court of law.
 Research. Provides valuable health-related data for
research.
 Statistics. Provides statistical information that can be
utilized for planning people’s future needs.
 Education. Serves as an educational tool for students
in health discipline.
 IMPORTANCE

• Audit & Quality Assurance. Monitors the quality

of care received by the client and the competence of
health care givers.
• Planning Client Care. Provides data which the entire
health team uses to plan care for the client.
• Reimbursement. Provides the basis for decisions
regarding care to be provided and subsequent
reimbursement to the agency, to cover health-
related expenses.
 C o m m u n ic a t io
• is a process in which people affect one another
n exchange of information, ideas, and
through
feelings.

MODES OF COMMUNICATION
• Verbal communication. Uses spoken or written
words.
• Nonverbal communication. Uses gestures, facial
expression, posture/gait, body movements,
physical appearance (also body language), eye
contact, tone of voice.
 Character i sti cs of communi cati on

▫ S im p l ic it y . Includes use of commonly understood

words, brevity and completeness.
▫ Clarity. Involves saying exactly what is meant. The nurse also
needs to speak slowly and enunciate words well. Repeat the
message as needed. Reduce distractions.

▫ Timing and Relevance. Require choice of

appropriate time and consideration of client’s interests
and concerns. Ask one question at a time. Wait for an
▫ answer before
Adaptability. makingadjustment
Involves another comment.
on client.
▫ Credibility. Means worthiness or belief. To become
credible:
-adequate
-provide accurate
information
-convey confidence and certainly in what
she says
-be a good model for what she teaches.
 C o m m u n ic a t io n is a basic component of human
relationships and nurse-client relationships.
• Is a dynamic, continuous and multidimensional process
for sharing information as determined by standards or policies.
• Non-ve rbal communic ation is a more acute
expre s s ion of a pe rs on’s thoughts and
fe e ling s than ve rbal communic ation.
• When assessing non-verbal behaviors, c o n s id e r
c u lt u r a lin f lu e n c e s . Variety of feelings can
be expressed by a single non-verbal expression. E.g. head
nodding does not always mean agreement.
• E f f e c t iv e c o m m u n ic a t io n is reciprocal interaction
(two-way process) based on trust and aimed at identifying client
needs and developing mutual goals

• Trust is a foundation of a positive nurse-client relationship.

 of nurse- client an effective
Relationship as follows
• An intellectual and emotional bond between the nurse and the
patient and is focused on the patient.
• Respects the client as an individual-his ability to
participate in his care, ethnic and cultural factors, family
relationship and values.
• Respects client’s confidentially.
• Based on mutual trust and acceptance.
 P E S
T Y
I NG
O F R D
E C O
R
 Ty p e s o f R e c o r
d
A.SOURCE ORIENTED
MEDICAL RECORD
> Each person or department makes notations in a
separate section/s of the client’s chart.
> Most Traditional
> Different disciplines chart on separate forms
> Each reader must consult various parts of the
record to get a complete picture
> Records become bulky
SOURCE ORIENTED MEDICAL RECORD
N A R R A T IV E C H A R T IN G ( T R A D
IT IO N A L C L IE N T R E C O R D )
▫ Most flexible of all methods and is usable in any
clinical setting.
F ive Basic components o f a Traditional Client
Record
 admission sheet
 physician’s order sheet
• Medical history
 Nurse’s notes
 Special records and reports (referrals, X-ray, reports, laboratory
findings, report of surgery, anesthesia record, flow sheets, vital
signs, I&O, Medications)
B. PROBLEM-ORIENTED MEDICAL
RECORD (POMR OR
POR)
– The record integrates all data about the
problem, gathered by the members of the health
team.
F O U R B A S IC C O M P O N E N T S O
P OMR/P O
F
R
• Database.
•• Initial
Problem listlist.
of orders or care plans.
• Progress notes:
◦ Nurse’s or narrative notes (SOAPIE format)
Subjective, Objective, Analysis, Planning,
• FlowEvaluation
Intervention, sheets (data that are
monitored)
• Discharge notes or referral
summaries
 Me tho d
s
(STYLES
OF
C )H A R T IN
G
• Nurs e ’ s
n
o ar r r a t iv e n o t e s
( S O A P IE f o r m a
S -)S UBJECTIVE.
• t WHAT PT TELLS
YOU . .
A – AS S E S S M WHAT
E N T.YOU THINK IS
• 0 –
ON OBJECTIVE. WHAT
GO YOU
ING
B A S E D O N
• YOUR
OBSERVE,DATA. SEE
• P – PLAN. WHAT YOU ARE GOING TO
DO.
CAN ADD TO BETTER REFLECT NURS ING
• I INTERVENTION (SPECIFIC
PROCES
– S
INTERVENTIONS
IMPLEMENTED)
• E–
INTERVENTIONS..PT RESPONSE TO
EVALUATION
• R – REVIS . CHANGES IN
TREATMENT.
 B . P IE
IN G
C H• Both are problem-oriented
•Si milar
• PIE comes from the Nursing Process, SOAP comes from a
Medical Model.
• P-Problem

A R T
• I-Intervention
to • E-Evaluation
SOA P char ting
Ex:
• P#1 Risk for trauma related to
dizziness.
• IP#1 Instructed to
call for assistance when getting OOB.
Call light in reach.
• EP#1
Consistently call for assistance
before getting OOB.
NAARRARTIVETDOCIUNMENTGATION
(DAR)

• DATA – SUBJECTIVE OR OBJECTIVE THAT SUPPORTS

THE FOCUS (CONCERN)

• ACTION – NURSING INTERVENTION

• RESPONSE – PT RESPONSE TO INTERVENTION

Ex:
• D – COMPLAINING OF PAIN AT INCISION SITE , PS: 7/10
• A – REPOSITIONED FOR COMFORT. DEMEROL 50MG
IM GIVEN.
• R – STATES A DECREASE IN PAIN, “FEELS MUCH
BETTER.”
D. COMPUTERIZED CHARTING
• PASSWORD. NEVER SHARE.
CHANGE FREQUENTLY.
• LEGIBLE
• CAN BE VOICE-ACTIVATED, TOUCH-
ACTIVATED.
• DATE AND TIME AUTOMATICALLY
RECORDED.
• ABBREVIATIONS AND TERMS ARE SELECTED BY
A MENU PROVIDED BY THE FACILITY.
• TERMINALS ARE USUALLY EASILY ACCESSIBLE,
IN PT ROOMS, CONVENIENT HALLWAY
LOCATIONS.
• MAKE SURE TERMINAL CANNOT BE VIEWED BY
K a r d e x
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 cards 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 – shift report. But
endorsement is not simply reciting content of kardex.
Health care needs of the client is still primary basis
for endoresement.
• Usually include the ff. data:
– Personal 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, mechanical ventilation.
• Entries usually written in pencil. This implies the
kardex is for planning ang communication purpose
only.
 GENERA
D O CLU M E N TA T IO N
Ensure that Gyou UhaveIDthe cEor
*

Lect IclNient ErecSord or chart.

* Document as soon as the client encounter is concluded
to
ensure ac urate recall of data.
* Date and time of each entry.
* Sign each entry with your full legal name and with your
profes ional credentials.
* Do not leave space in between entries.
* If an er or is made while documenting, use a single line
to
cros out the er or, then date, time and sign the cor
ection
* Never change another person’s entry even if it is incor
ect
* Use quotation marks to indicate direct client responses.
*
 o f Go o d
• B R E V IT
Y– Entries o r d in g :
R earecconcise
– 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.

• USE INK/PERMANENCE
– Avoid pencil for permanence of data, because
the client’s chart can be used as an evidence in
a legal court.
• ACCURAC
Y– Chart objective facts, not your interpretations
or opinions
– Eg.
Ate 50% of the food served.
Ate with poor appetite.
Refused medications.
Uncooperative.
Seen crying.
Depressed.
– Place complaint of the client in
quotation marks to indicate that it is
his statement.
“chest pain radiating down the left arm”
“nahihirapan akong huminga kapag
nakahiga”

– Objective data are also to be

charted.
E.g. skin cold and clammy.
Diaphoretic. Prefers to sit up. Vital
signs taken as follows: temp-37.6C,
PR-110/min., RR-26/min. BP-140/90
mmHg.
 – Describe behaviors rather than feelings to allow
other health team members to determine the
actual problems of the client.
– Refusal of medications and treatments must be
documented.

• A P P R O P R IA T E N E S S
– Only information that pertains to the
client’s health problems and care are
recorded.
– Any other personal information that is
conveyed to the nurse is appropriate for the
record.
• Completeness and
chronology/organization/seque
nce/timing.
– Notes should appear on each succeeding line
– Continuous charting is done for each entry unless a time
change 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
page 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 the nurse’s notes, unless
there is an alternation from the normal, e.g. body temperature,
blood pressure.
– Avoid squeezing information to a space because you forgot
to chart it earlier. Add the information on the first available
line.
Write the time the event occurred, not the time you entered
The following information should be charted:
o Physician’s visits.
o Times the patient leaves and returns to the unit, mode of transportation and
destination.
o Medications should be charted immediately after administration.
o Treatments should be charted immediately after being done.

• Us e o f s t a n d a t e r m in o lo g

r d Use only those abbreviations
y
correctly; use proper grammar.
and symbols approved by the institution; spell

• Signed.
 Affix signature, place at the end of charting, at the right hand margin of the
nurse’s notes.
 Sign each entry with your full name and status, e.g. SN for Student Nurse,
RN for registered nurse.
 Script, not printing is used for the signature.

• In c a s o f e r r o
* Correct errors by drawing a single horizontal line
* e
through the error r.
* Write the word error above the line, then sign
* your signature
* No ink eradication, erasures or use of occlusive materials.
 • C o n f id e n t ia l it
–
 Only the health personnel who participate in the
y
• Le
.
care of the client are allowed to read the chart.
g a l a w a re ne s s
– Chart only what you personally have done, observe,
heard, smelled, or felt.
– Do not discard any of the client record.

• L e g ib le
– Writing must be clear and easily read by others
– If writing is not legible, then print.
• 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.
 Needs attended. Referred accordingly.-------Ma.
 R T
P O
R E G
N
I
 – takes place when two or more people share
information about client care , either face to face or
by telephone.
Ty p e s o f r e p o r t in g
REP ORT
• W a lk in g ro unds
IN G
• change – of – shift reports or
endorsement
– for continuity of care
– it is based on health care needs of the client
– it is not mere reciting the content of the kardex
• Telephone reporTs
– provide clear accurate and concise information
– the nurse documents telephone report by including the
following information:
• when the call was made
• who made the call/report
• who was called
• to whom information was given
• what information was given
• Te le p h o n e o r d e
r––sOnly RN’s may receive telephone orders
The order need to be verified by reporting it clearly
and precisely.
– The order should be countersigned by the physician
who made the order within the prescribed period of
time (within 24 hours)
• Tr a n s fe r re po rts
– this is done when transferring a client from unit
to another.

• Incident Reports or occurrence reports

– Used to document any unusual occurrence or
accident in the delivery of client care
 GRO UP A c t iv it
S it u a t io
•n :A n t o n io , 5 5 yy / o f a r m e r, w a s
f oau n d b y h is s o n ly in g o n t h
fe lo o r u n c o n s c io u s . H e w a s
bro ug ht to the ER a nd w a s
d ia g n o s e d w it h C VA , p r o b a b
b le e d . H e isly t h e n a d m it t e d t
to h e m e d ic a l IC U f o r c o n t in u it y o
fc r it ic a l c a r e . H e is d
ro w s y,
rd ey ss tplen se sic a, ta n
t im e sit, hs ee xv ec re es ly
d w s iv e
s e c r e t io n s . C r a c k le s a r e h e a r
u
d p o n a u s c u lt a t io n a t b o t h lo w e r
lu n g f ie ld s . V / S : B P
190 /110 m m Hg , T°