Maintenance of Documentation

What is Documentation?
• Anything written or printed as a record or
proof for authorized person
• Documents serves as a permanent record of
client information and care
• Essential part of nursing practice with clinical
and legal significance.
• Good quality documenting is linked with
improvements in patient care, while poor
standards of documentation are regarded as
contributing to poor quality nursing care
 Formats of Documentation
• Source – Oriented
• Problem – Oriented
• PIE (problems, Interventions, and Evaluation)
• Flow Chart
• Focus Chart
• Charting by Excepting
• Computerized Documentation
• Case Management
 Common forms used in
documentation
• Nursing Admission data form
• Discharge Summery
• Flow sheets & Graphic records(allow to see patterns
of change in patients status)
• Medication Administration Records
• Nurses Progress Notes
• Kardex
Common forms used in documentation ctd

• Temperature chart
• Drugs Chart
• Fluid balance chart
• Observation chart
• Sugar chart
• Weight Chart
• BP chart
Common forms used in documentation ctd
• Admission book
• Drugs Books – Daily drugs, Countable Drugs,
Weekly Drugs, Local purchase Drugs, Antibiotics,
Infusions
• Mid Night Report
• Day and Night report
• Nurses Notes
• Correspondence Book
• Information book
• Duty roster
• Giving over and Taking over book
 Documentation must be
• clear,
• concise,
• comprehensive,
• accurate,
• objective, and timely
• Maintain continuity of care
• Track client outcomes
• Minimize the error
 Guidelines of quality
Documentation and Reporting
• Factual
• Accurate
• Complete
• Current
• Organized
• Recording and reporting
 What is recording?
• Medical records are a significant type of
document
• Medical records are very useful in entire life to
all people
• It is used for legal aspect also
• Medical records found in hospitals are
systematic documentation of patients’ medical
care and history
 What is recording? Ctd…
• Traditionally, medical records were
documented in paper form
• Current world -development of the electronic
health record (EHR)
• Medical records can be found in three primary
formats: electronic, paper, and hybrid.
 Importance of medical record
• Reduces risk of malpractice
• Helps to maintain communication amongst
healthcare personnel
• Ensure you get reimbursed
• Measures hospital quality
 Components of medical records
• Identification Information
• Medical History
• Medication Information
• Family History
• Treatment History
• Medical Directives
• Lab results
• Consent Forms
• Progress Notes
• Financial Information
 What is Reporting?
Takes place when two or more people share information
about client care, face to face or by telephone or through
the written reports

It summarizes the current critical information relevant

to clinical decision making and continuity of care

It is not a Documentation
 What is Reporting? ctd
• If any Emergency or Important thing reports,
• It should be documented within 24 hours
Ex – Patient missing
Accidents
Assaults
 Types of reports
• 1.Walking Rounds-
Daily rounds,
ward round (Morning/Evening/Night/special)

• 2. Change of shift reports or endorsement

for continuity care
It is based on health care needs of the client
It is not mere reciting the content of the kardex
 Types of reports ctd
• 3.Telephone reports or orders
Have to provide clear accurate and concise information
Should document 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
What information was received
 Types of reports ctd
• 4. Transfer reports
This is done when transferring a client from unit to
another
5. Incident reports or occurrence reports
Used to document any unusual occurrence or
accident in the delivery of client care

.
 Maintains nurses notes and other
records of client
• Every entry should have the time, date, and sign on it
• The person making any entries should write their
role and name
• Make sure to document everything as quickly as
possible
• Abbreviations should only be used if they are
approved
• Addendums made should be communicated to all
nursing staff and teams.
 Maintains nurses notes and other records
of client ctd…
• If any mistake has been made, a single strike should
be made through the entry
• Once it is corrected, it should be signed and dated
• The SOAP method, which stands for: Subjective,
Objective, Assessment, and Plan, is what is used for
effective documentation by medical staff.
 The Uses of Nursing
Documentation
• Communication with Other Professionals
• Reimbursement
• Research
• Quality process and performance improvement
• Statistics
• Education
• Audit and quality assurance
• Planning client care
•
The Uses of Nursing Documentation ctd

• provides a full accounting of patient care to support

reimbursement,
• ensure quality care
• reduce errors
• can be used as evidence in legal matters
• generates data for research and quality improvement
initiatives.
THE END
 Assessment
• 1. What are the importance of doing the
documentation as a nurse?
• 2. When you are doing documentation what
are the special consideration do you have as a
nurse?
• 3. As a nurse what information do you
document?
• 4.What is the reporting ?
• 5. What are the components of medical
records?
• 6. What are the type of reports?
• 7. What are the common forms can be used in
your ward or unit?
 Answers
• 1. Communication with Other Professionals (Doctors,
Consultants, Nursing staff, MLTs,Physiotherapists ,etc..)
• Quality care (Planning client care, continue care,, maintain
interpersonal relationship, Timely care, Minimize mistakes)
• Ensure quality care
• provides a full accounting of patient care to support
reimbursement, (Requesting insurances etc..)
• Quality process and performance improvement
• Statistics purpose
• Education Purpose
• Improve Nurses knowledge and skills
• Audit and quality assurance
• can be used as evidence in legal matters
• Generates data for research and quality improvement initiatives.
 2. When we keep the documentation it should be
• clear,
• concise,
• comprehensive,
• accurate,
• objective, and timely
• Maintain continuity of care
• Track client outcomes
• Minimize the error
3 .Patients admission to discharge, Admission information
such as personal details, about current disease condition,
past medical history, family history etc..
• All given Care, procedures, investigations, referrals,
Medications, Continue care plan
• Nurses have to maintain these documents such as Drugs
Books – Daily drugs, Countable Drugs, Weekly Drugs,
Local purchase Drugs, Antibiotics, Infusions
• Mid Night Report
• Day and Night report
• Nurses Notes
• Correspondence Book
• Information book
• Duty roster
• Giving over and Taking over book
• 4.Reporting is two or more people share information
about client care, face to face or by telephone or
through the written reports
• If any Emergency or Important thing reports,It should
be documented within 24 hours
Ex – Patient missing
Accidents
Assaults
5. Identification Information
• Medical History
• Medication Information
• Family History
• Treatment History
• Medical Directives
• Lab results
• Consent Forms
• Progress Notes
• Financial Information
• 6. .Walking Rounds
• Change of shift reports or endorsement
• Telephone reports or orders
• Transfer reports
• Incident reports or occurrence reports
7. Nursing Admission data form
• Discharge Summery
• Flow sheets & Graphic records(allow to see patterns of change in
patients status)
• Medication Administration Records
• Nurses Progress Notes
• Kardex
• Temperature chart
• Drugs Chart
• Fluid balance chart
• Observation chart
• Sugar chart
• Weight Chart
• BP chart