DOCUMENTATION:-

 Documentation is defined as written evidence of: • The

interactions between and among health professionals,
clients, their families, and health care organizations. •
The administration of tests, procedures, treatments,
and client education. • The results or client’s response
to these diagnostic tests and interventions.
 Documentation is anything written or printed on which
you rely as record or proof of patient actions and
activities.
MAINTENANCE OF
RECORDS AND REPORTS
 DEFINITION OF RECORD

 Record is written or computer based, the process

of making an entry on a client’s record is called
recording, charting, or documenting.

 A clinical record, also called a chart or client

record is a formal, legal document that provides
evidence of a client’s care.
 Purposes of Client Records
1- Communication: The record serves as the vehicle
by which different health professionals who
interact with a client communicate with each
other.
.
2- Planning Client Care: Each health professional
uses data from the client’s record to plan care for
that client.

3- Auditing Health agencies: An audit is a review of

client records for quality assurance purpose.
4- Research: The information contained in a record
can be a valuable source of data for research. The
treatment plans for a number of clients with the
same health problems can yield information
helpful in treating other clients.

5- Education: A record can frequently provide a

comprehensive view of the client, illness,
effective treatment strategies, and factors that
affect the outcome of the illness.

 - To provide the practitioner with data required

for the application of professional services for the
improvement of family’s health.

 - A record indicates plan for future

GUIDELINES FOR MAINTAINING
RECORDS:

Because the client’s record is a legal document

and may be used to provide evidence in court,
many factors are considered in recording:

1- Date and Time: document the date and time

of each recording. This is essential not only
for legal reasons but also for client safety.
Accurate according to the 24-hours clock or
in the conventional manner (am, pm).
2- Timing: follows the agency’s policy about the
frequency of documenting, and adjusts the
frequency as a client’s condition indicates. No
recording should be done before providing
nursing care.

3- Legibility: all entries must be legible and easy

to read to prevent interpretation errors.

4- Permanence: all entries made in dark ink so

that the record is permanent and changes can
be identified.
5- Correct Spelling: is essential for accuracy in
recording. Incorrect spelling gives a negative
impression to the reader and, thereby,
decreases the nurse’s credibility.

6- Signature: each recording on the nursing

notes is signed by the nurse making it. The
signature includes the name and title. For
example, Ms. Ankita, RN.
7- Accuracy: the client’s name and identifying information
should be stamped or written on each page of the clinical
records. Before making any entry, check that it is the correct
chart.
 It is more accurate, for example, to write that the client”
refused medication” (fact) than to write that the client “was
uncooperative” (opinion).
8- Sequence: document events in the order in which they occur,
such as record assessments, then the nursing interventions, and
then the client’s responses.

9- Appropriateness: records only information that pertains to

the client’s health problems and care. Recording irrelevant
information may be considered an invasion of the client’s
privacy.
10- Completeness: not all data that a nurse obtains about a client
can be recorded; however, the information that is recorded
needs to be complete and helpful to the client and health care
professionals. Nurse’s record need to reflect the nursing
process, record assessment, dependent and independent
nursing interventions, client problems, client comments and
responses to interventions and tests, progress toward goals.
12-Conciseness: recording need to be brief as well as complete
to save time in communication.

13. Accepted Terminology: Use only commonly accepted

abbreviations, symbols, and terms are specified by the agency.
Many abbreviations are standard and used universally.

14. Legal Prudence: accurate, complete documentation should

give legal protection to the nurse, the client’s other caregivers,
the health care facility, and the client.
 VALUE AND USE OF
RECORDS
FOR A NURSE -:
 The record provide basic facts for
services.
 Provides a basis for analyzing the
needs in terms of what has been done,
what is being done ,what is to be done
 It serves as a guide to professional
growth.
 It enable the nurse to judge the quality
& quantity of work done .
FOR THE FAMILY AND INDIVIDUAL:-

 The record help to become aware of & to

recognize their health needs .
 A record can be use as a teaching tool too.
 The health records or any investigations done
in any other institutions will be helpful for an
effective diagnosis and treatment.
FOR THE DOCTOR:-

 The record serve as a guide for diagnosis ,

treatment & evaluation of services.
 It indicate progress of the patient and
continuity of care.
 It may be use in research.
FOR THE ORGANISATION AND
COMMUNITY:-
 The record help the supervisor to evaluate the
services.
 It help in guidance of staff & students.

 Help in research.

 It provide a justification for expenditure of funds.

 It helps the administration in assessing the

performance of their own institutions and the needs
of the society.
TYPES OF RECORDS
1.FAMLY RECORDS:-

 The family folder which contain all the

individual record of one family.
 All the record which relate to members of one
family should be placed in the single family
folder. In this way the doctor & health workers
can see the total situation & give effective
economical service to help the family as a
whole.
2. ANECDOTAL RECORDS:-
It is a brief description of an observed behavior
that appears significant for evaluation
purposes, done by community health nurse
during home visit.

3. CLINICAL RECORD:- It is used in the

hospital; investigations special treatments &
procedures written & sign.
4. DOCTORS ORDER
SHEET:-
Doctor order regarding
medications , investigations,
special treatments &
procedures written & signed.
5.NURSES SHEET :-
Nurses notes are a record
of treatments & nursing
measures carried out by
the nurses , their effect
the observations made
on the patient.
OTHER RECORDS:-
TPR chart, lab report sheet, diet sheet, intake
output chart, anesthesia chart, physiotherapy
sheet, special treatment sheets etc.
Progress Notes

Is a chart entry made by all health professionals involved in a

client’s care, they all use the same type of sheet for notes. For
example, the SOAP format is frequently used.
S – Subjective data consist of information obtained from what the
client says. It describes the client’s perceptions of and
experience with the problem.
O – Objective data consist of information that is measured or
observed by use of the senses(e.g., V/S , Lab test, X-ray
results).
A – Assessment is the interpretation or conclusions
drawn about the subjective and objective data.
’’A’’ should describe the client’s condition and
level of progress rather than merely restating the
diagnosis or problem.
P- Plan is the plan of care designed to resolve the
stated problem.
The SOAP format has been modified to SOAPIER
I- Interventions refer to the specific interventions
that have been performed by the caregiver.
E- Evaluation includes client responses to nursing
interventions and medical treatments.
R- Revision reflects care plan modifications
suggested by the evaluation.
 REGISTERS
Registers maintains the statics. In all community health centers,
hospital system &educational institutions maintain registers.

IN HOSPITAL
 birth & death register

 census register

 admission , discharge register

 OPD register, stock register

IN COMMUNITY
 Immunization register

 Health care register

 Clinic attendance register

 Family planning register

 Birth & death register

 Stock register
CONTD…
 Mother care register
 Monthly report register
 General information register
 School health register
 Eligible couple register
REPORTS
 INTRODUCTION

 Reporting is the verbal or written communication

of data regarding the client’s health status, needs,
treatments, outcomes & responses.

 It facilitates clinical decision making, continuity

of care & coordination among the health team
members.
DEFINITION
 Report is an oral or written account by one
member to another in the health team which
includes the end of shift handing over the report.
 It offers a summary of activities or observation
seen, performed or heard which is exchanged
among health care team members, clients &
family members.
 For giving concise, efficient & organized
report nurse must think about-
 what needs to be said?

 why it need to be said?

 how to say?

 what the expected outcomes are?

 ELEMENTS
 Timings
 Organization

 Clarity
 Correctness
 PURPOSES OF WRITTEN REPORTS
 To show the kind & amount of services rendered
over a specified period.
 It helps to illustrate progress in reaching goals.
 It acts as an aid in studying health condition.
 It aids in planning.
 It helps to interpret the services to the public & to
other interested agencies.
 Types
1) Oral reports – It is sometimes used in
emergency & followed by a written
report later.
An oral report is made by the nurse who
is assigned to patient care , to the another
nurse who is supposed to relieve her.
2) Written reports - It should concentrate
on the past, present & future state of the
patient . Description & conclusion of the
state influences further planning &
decision making. Daily, weekly, monthly
& annual reports are its further types.
 CONTD…..

3) 24 hours report – It keeps nursing supervisor &

nursing administrative personnel informed of
what is happening in all patient care areas.
4) Census report – It includes the daily census or
the no. of patients admitted in the hospital. This
report helps in planning of health care services
& knows about the morbidity & mortality
statistics.
5) Accidental reports – It
includes writing a detailed
report on mistakes or accidents
that has taken place in the care
of pateint’s. It should be
promptly informed to the
higher authorities by writing
accidental reports.
6) Change of shift report – At
the end of each shift, nurse’s
report information about their
assigned clients to the nurses
working on the next shift.
7) Transfer report – It involves communication of
information about client from nurse to the nurse on the
receiving unit.

8) Telephone Reports- health professionals frequently

about a client by telephone. Nurses inform primary care
providers about a change in a client’s condition.
- The nurse receiving a telephone report should document the
date and the time, the name of the person giving the
information, and the subject of the information received.
- The person receiving the information should repeat it back to
the sender to ensure accuracy.
 - When giving a telephone report to a primary care
provider, begin with name and relationship to the client.
For example “This is Maher , RN, I’m calling about your
client, jhon. I’m her nurse on the 7pm to 7am shift’’.
- Telephone reports usually include the client’s name and
medical diagnosis,…ect. The nurse should have the
client’s chart ready to give any further information.
9) Telephone Orders - physicians often order a
therapy for a client by telephone. While the
primary care provider gives the order, write the
complete order down and read it back to ensure
accuracy. Question about any order that is
ambiguous, unusual, or contraindicated by the
client’s condition.
10) Nursing Rounds - procedures done to:
- Obtain information that will help plan nursing
care
- Provide clients the opportunity to discuss their
care
- Evaluate the nursing care the client has received.
During rounds, the nurse assigned to the client
provides a brief summary of the client’s nursing
needs and interventions being implemented.
ROLE
OF
NURSE
CARE OF DOCUMENTS:-
 It should kept under the safe custody
of nurse in each ward.
 No individual sheet is separated from
the complete record.
 It should kept in a place ,not
accessible to the patients & visitors.
 It are never sent out of the hospital
without doctor’s permission.
 Handle the documents carefully
FILLING OF RECORD:-
 It should be correctly filled.
 these are set up &maintained in a systematic
planned & organized manner.
 Can be arranged alphabetically &
numerically.
CONFIDENTIALITY
 Confidentiality can be defined as the ethical
principle or legal right that a physician or other
health professional will hold secret all
information relating to a patient, unless the
patient gives consent permitting disclosure.
CONT…..
 “The ethical principle or legal right that a
physician or other health professional will hold
secret all information relating to a patient, unless
the patient gives consent permitting
disclosure”(American Heritage Medical
Dictionary, 2007).
IMPORTANCE OF CONFIDENTIALITY
 Patients routinely share personal information with
health care providers. If the confidentiality of this
information were not protected, trust in the physician-
patient relationship would be hard to maintain.
 Creating a trusting environment by respecting patient
privacy encourages the patient to seek care and may
also increase the patient’s willingness to seek care.
 Confidentiality safeguards information that is
gathered in the context of an intimate relationship