Biniyam D Fundamentals of Nursing 05/14/2022

COLLEGE OF HEALTH SCIENCES

SCHOOL OF NURSING

FUNDAMENTALS OF NURSING

By: Biniyam D. (BSN, MSN)

September, 2021
Arbaminch, Ethiopia 1
 Biniyam D Fundamentals of Nursing 05/14/2022

Documentation and Recording

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LEARNING OBJECTIVES:

After completing this unit, the learners will be able to:

 Explain the purposes of documentation in health care

 Describe the principles of effective communication

 Describe various methods of documentation

 Describe various forms of recording data

 Define reporting

 Discuss types of reporting

 Discuss the caring modalities for a patient on admission

and discharge

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Documentation as Communication
 Communication:
 Is a dynamic, continuous, and multidimensional
process for sharing information
 Reporting and recording are the major
communication techniques
 Medical record serves as a legal document for recording
all client activities
 Documentation provides a written records that reflect
client care provided and the client’s response to
interventions

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Documentation

Documentation is defined as written evidence of:

1. The interactions among health professionals, clients,
their families, and health care organizations
2. The administration of tests, procedures, treatments, and
client education
3. The results or client’s response to these diagnostic tests
and interventions

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Documentation: PURPOSES

Purposes of Health Care Documentation

 Professional responsibility and accountability
 Communication

 Education
 Research

 Meeting legal and practice standards, and

 Reimbursement: to monitor and evaluate the quality and
appropriateness of care given

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Documentation: PRINCIPLES

Principles of Effective Documentation

 Documentation requirements will differ depending on
 The health care facility (hospital, nursing home, home
health agency)
 The setting within the facility (e.g., Emergency room,
perioperative, medical-surgical unit)
 With specific client populations (e.g., obstetrics,
pediatrics, geriatrics)
 Regardless of what client care is administered, the
documentation of that care must reflect the nursing
process
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 Principles…

General Documentation Guidelines

 Ensure client’s name and identifying information are on
every page of the record
 Document as soon as the client encounter is concluded
 Date and time each entry

 Sign each entry with your full legal name and with your
professional credentials
 If an error is made, use a single line to cross out the
error; avoid erasing, crossing out, or using fluid

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 Principles…

General documentation guidelines…

 Never change another person’s entry, even if it is
incorrect.
 Use quotation marks to indicate direct client responses
 Document in chronological order

 Write legibly
 Use a permanent-ink pen (black is usually preferable)

 Document in a complete but concise manner

 Document all telephone calls that are related to a
client’s case

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Documentation: ELEMENTS

Elements of Effective Documentation

 Effective documentation requires:
 Use of a common vocabulary

 Legibility and neatness

 Use of only authorized abbreviations and symbols

 Factual and time-sequenced organization

 Accurately including any errors that occurred

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Documentation: METHODS

Methods of Documentation includes:

 Narrative charting
 Source-oriented charting

 Problem-oriented charting
 PIE charting

 Focus charting
 Charting by exception (CBE)

 Computerized documentation
 Case management with critical paths

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 Methods…

Narrative Charting
 The traditional method of nursing documentation
 Is a story format that describes the client’s status,
interventions and treatments, and the client’s response
to treatments
 Easy to use in emergency situations, in which a simple,
chronological order is needed
 Narrative charting is now being replaced by other
formats

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 Methods…

Source-Oriented (S.O.) Charting

 Described as a narrative recording by each member
(source) of the health care team on separate record
 Care is often fragmented and communication between
disciplines becomes time-consuming
 Nurses use an unstructured approach in documenting in
the progress notes

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 Methods…
Problem-Oriented Charting
 Problem-oriented medical record (POMR): introduced in
1969
 The focus is on the client’s problem, with a structured,
logical format to narrative charting called SOAP:
 S: subjective data (what the client or family states)

 O: objective data (what is observed/inspected)

 A: assessment (conclusion reached on the basis of data

formulated as client problems or nursing diagnoses)
 P: plan (actions to be taken to relieve client’s problem)

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 Methods…

Problem-Oriented Charting…
 SOAPIE and SOAPIER refer to formats that add:

 I: intervention (measures to achieve an expected

outcome)
 E: evaluation (effectiveness of interventions)

 R: revision (changes from the original plan of care)

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 Methods…

PIE Charting
 Problem, intervention, evaluation (PIE) system
introduced in 1984
 SOAP was developed on a medical model, PIE charting
has a nursing origin
 Each client problem is labeled and numbered for easy
reference
 Eliminates the traditional care plan by incorporating an
ongoing plan of care into the daily documentation

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Biniyam D Fundamentals of Nursing 05/14/2022

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 Methods…

Focus Charting
 Focus charting was created in 1981
 Is a method of identifying and organizing the narrative
documentation of client concerns to include data, action,
and response
 Is not limited to client “problems” but allows for the
identification of all “concerns” such as a significant
event (e.g., Results of a diagnostic test)
 Uses a columnar format within the progress notes to
distinguish the entry from other recordings in the
narrative notes
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 Methods…

Charting by Exception
 Charting by exception (CBE) was instituted in 1983
 Is a charting method that requires the nurse to document
only deviations from preestablished norms.
 The CBE system has three key components:

1. Flow sheets: highlight significant findings and define

assessment parameters and findings
2. Reference documentation: is related to the standards
of nursing practice
3. Bedside accessibility: requires the nurse to document
significant findings
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 Methods…

Computerized Documentation
 Nursing information systems (NIS) are being developed
that will complement existing hospital information
systems (HIS)
 The NIS will collect, store, process, retrieve, display,
and communicate timely information that supports:
 Administration of nursing services and resources
 Management of standardized client care information

 Linkage of research resources and educational

applications to nursing practice

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 Methods…

Case Management Process

 Defined as a methodology for organizing client care
through an episode of illness
 Contains daily assessment documentation, care plan,
outcome oriented multidisciplinary interventions,
teaching, and discharge planning

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 FORMS FOR RECORDING DATA
 There are several types of forms used in record keeping:
 Kardex,

 Flow sheets,

 Nurses’ progress notes, and

 Discharge summaries.

 All of these forms are designed to facilitate record

keeping, reduce duplicate activity, and ensure quick
and easy access to information

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 Forms…

Kardex
 A Kardex (client profile and client summary sheets) is a
summary worksheet reference of basic client care
information
 Is not part of the medical record
 Is a concise client data source, is used as a reference
throughout the shift and during change of-shift reports.

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 Forms…

The Kardex usually contains the following information:

 Client data: name, age, marital status, religious
preference
 Medical diagnoses: listed by priority

 Nursing diagnoses: listed by priority

 Medical orders: diet, medications, diagnostic tests and

procedures
 Activities permitted: functional limitations, assistance
needed in activities of daily living, and safety
precautions

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 Forms…

Flow Sheets
 Have vertical or horizontal columns for recording dates
and times to show assessment and interventions,
making it easy to track changes in the client’s condition
 Client teaching, use of special equipment, and IV
therapy are other aspects of the flow sheet
 The information on the flow sheet can be formatted to
meet the specific needs of client populations

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 Forms…
Nurses’ Progress Notes
 Are used to document the client’s condition, problems, and
complaints; interventions; response to interventions; and
achievement of outcomes
 Include the following forms:

 Nurses’ notes, medication administration record (MAR),

personal care flow sheets, teaching records, intake and
output forms, vital sign records, and specialty forms (e.g.,
diabetic flow sheet and neurologic assessment form)
 Can be completely narrative or incorporated into a
standardized flow sheet

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 Forms…

Discharge Summary
 Highlight the client’s illness and course of care

 When a narrative discharge summary is entered into the

progress notes, it includes:
 The client’s status at admission and discharge

 A brief summary of the client’s care

 Intervention and education outcomes

 Resolved problems and continuing care needs

 Client instructions regarding medications, diet, food

drug interactions, activity, treatments, follow-up
instructions, and other special needs
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REPORTING
 Is the verbal communication
of data regarding the client’s
health status, needs,
treatments, outcomes, and
responses
 When a report is given, it
needs to summarize the
current critical information

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 Reporting…

Types of reporting:
 Summary reports

 Walking rounds

 Telephone reports and orders, and

 Incident reports

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Reporting: Types

Summary Reports
 Summarize pertinent client information that focuses on
the client’s needs
 Commonly occur at the change of shift and when the
client is transferred to another area
Walking Rounds
 Reporting method used when the members of the care
team walk to each client’s room and discuss care and
progress with each other and with the client
 Can be either nursing rounds, physician nurse rounds, or
interdisciplinary rounds
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Reporting: Types

Telephone Reports and Orders

 Nurses report transfers, communicate referrals, obtain
client data, solve problems
 Inform a physician and/or client’s family members
regarding a change in the client’s condition
Incident Reports
 Incident reports, or occurrence reports, are used to
document any unusual occurrence or accident in the
delivery of client care, such as falls or medication errors

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Caring for a Patient on Admission & Discharge

Caring for a patient during admission

 Admission is the entry of a patient in to a hospital ward
for therapeutic or diagnostic purpose.
 Purpose
 To provide immediate care safety and comfort

 To observe sign and symptoms, and general

conditions of the patient
 To enable the patient to use facilities, resource &
personal of the hospital
 To alleviate fear, worry & loneliness about the
hospital
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Caring for a patient during admission…

 Equipment Necessary Supplies such as
 Bath basin
 Bed (open bed)
 Tissue paper
 Articles for physical  Soap
examination  Hospital gown

 B/P apparatus  Slipper

 Towel
 Stethoscope
Special Equipment & Supplies if
 Weight balance
necessary such materials are
 Thermometer  Suction machine

 Cardiac monitoring
 Patient chart
 Oxygen

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Caring for a patient during admission…

Patient Admission procedure

 Check for orders of admission
 Prepare and ventilate the patients room

 Accompany patient to the room

 Introduce your self to the pt. and the family

 Explain what will occur during the admission process

and then give admission bath, put on hospital gown with
adequate privacy
 Orient the patient about, bed bath room, call light, etc to
make know how they work for patient use

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 Patient admission procedure…
 Explain to patient & relatives about visiting time and other
hospital routine.
 Perform base line assessments that are observation and
physical examination. (VIS, Weight, height, etc.) and
interview patient.
 Take care of patient’s personal property. Make list of the
valuables of the pt. then hand over to his relative or to word
in charge to be kept in locked cupboard.
 Record all parts of the admission process.
 Notify Hospital kitchen about diet.
 Prepare Kardex card & medication records.
 Write admission note on nurse’s report.
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Caring for a patient during admission…
Patients admission format (Chart)
 Name of patient

 Sex, Age

 Room No& bed No

 Doctor’s name

 Date & time of admission

 Method of admission.(with stretcher or wheelchair)

 Record of vial signs, height and weight

 Patient’s chief complain

 Signs & symptoms

 Collection & description of specimen

 Signature of the reporter.

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Caring for a Patient on Discharge
 Patient discharge:
 Sending the hospitalized patient to home or to referral
after successful discharge planning process
 Patient discharge Planning
 Is systematic process for preparing the patient to leave
the hospital & for continuity of care at home.
 Purpose
 To continue self care at home

 To adjust the patients setting out of the hospital

 To ensure adequate home health care support

 To minimize the patient’s anxiety at discharge

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 Caring for a patient on discharge…
Procedure
 Check for the order that pt. to be discharged.

 Send admission card to registration office

 Assist patient to dress up

 Collect personal belongings of the pt.

 Instruct the patient about:

 Medication

 Treatment (wound care etc.)

 Activity

 Diet

 Follow up

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 Caring for a patient on discharge…

Procedure…
 Check receipt before sending pt.

 Accompany patient to the gate. If possible

 Record time & date of discharge.

 Do terminal cleaning of the unit.

NB. If the patient insist, him/her self to leave the hospital

against medical advice.
He/ She should be requested to sign a statement indicating
that he/she is responsible for that action

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 Caring for a patient on discharge…

Patient discharge format: consists the following

 Description of the patient (Name, age , sex, etc)
 Date and time of discharge.

 Apparent conditions of patient (including V/s weight

and any deficits)
 Means of discharge (using wheelchair or stretcher)
 Current medications & treatments as well as diet
activity level and any restrictions.
 Follow up visit time.

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