College of Medicine and Health

Sciences

School of Nursing and Midwifery

Module Name:Fundamentals of nursing
unit6: Basic technique

Topic: Documentation care and

Reporting care.

By co-Facilitator:...............
 GENERAL OBJECTIVES
• Define documentation
• Importance of documentation
• Types of Documentation
• Do and don’t in Documentation
• Discuss forms of documentation.
 DEFINITION

• Documentation is the act of recording clients status and care in a

written form.
• Documentation is any printed or written record of activities.
 Purpose of documentations
• Communication
• Education
• Legal document
• Quality assurance
• Research
• Nursing Audit
• Health care analysis
 PRINCIPLE OF RECORDS
Timely
Objective and accurate
Complete
Concise
Legible
 DOCUMENTATION
• After complete the nursing assessment form or notes
as specified by your institution.

• The form include the patient’s:

vital signs,
Height and weight,
 Cont.
allergies, drug and health history,
a list of his belongings and those that he sent home with family
members,
the results of your physical assessment, and a record of specimens
collected for diagnostic tests.
 Cont.
• The mode of departure and name of the patient’s
escort, and a summary of the patient’s hospitalization
if necessary.
DOCUMENTATION FORMS

ADMISSION NURSING ASSESSMENT

NURSING CARE PLANS

KARDEXES: The system consists of a series of cards kept in a

portable index file or on computer-generated forms.
FLOW SHEETS: A Flow sheet enables nurses to record nursing data
quickly and concisely and provides an easy-to-read record of the
client’s condition over time. Examples include:
Medication Administration Record(Drug administration
Intake and Output Record(Fluid balance charts)
Graphic Record(Vital signs charts)
 Cont.
PROGRESS NOTES:Is the notes made by
nurses provided information about the
progress a client is making towards
achieving desired outcome.

NURSING DISCHARGE/ REFERRAL

 DOCUMENTATION

Vary depending on hospital

Record the time and date of discharge,

physical condition, special dietary or activity

instructions,
The type and frequency of home care

procedures, drug regimen, the dates for next

appointments,
 Do’s and Do Not’s in Documentation
Do’s
Use objectives , specific and factual description
Correct the charting errors
Review your notes
Do Not’s
Leave blank space for a colleague to chart later
Use vague terms
Record assumption or a word reflecting bias
 Conclusion

• Documentation is the act of recording client’s status and care in the

written form. Client records are legal documents that provides
evidence of a Client’s care.
 REPORTING CARE

Reporting is a communication between care providers that

follows a structured format and typically occurs at the start and
end of every shift or whenever there is a significant change in
the resident.
 Cont.
WRITTHEN REPORTS
These are reports that are written when the information to be used by
several personnel which is more or less of permanent.
ORAL REPORTS
These are reports that are done orally between healthcare providers.
 TYPES OF REPORTTING
Change of shift reports
Transfer reports
Incident reports
Telephones reports
 Cont.
Change of Shift Reports

 This is the type of report commonly using

at the end of each shifts nurses/midwives report information about

their assigned client’s to the nurses working on thenext shift.

 The report provides continuity of care among healthcare providers.

 Cont.

TRANSFER REPORTS

 Patient’s are often transfer from one unit to another to

receive different levels of care and treatment.

Eg: Transfer from ICIU to maternity unit when a client is stable

no longer requiressuch intense monitoring.
 Cont.
INCIDENT REPORTS.
 An incident report is thorough documentation of the incident,
including all relevant details that caused it and any outcomes that
stemmed from it
 These are major part of a unit quality improvement program. These
may include clinical or non-clinical incidents reports
 Cont.
Telephone reports

These are reports that are done through the phones regarding changes
in patient condition during caring and communicating information.
 REFERANCES
Myra Sandquist Reuter, M.A. (n.d.). 1.5 Documenting and
Reporting. wtcs.pressbooks.pub. [online] Available at:
https://wtcs.pressbooks.pub/nurseassist/chapter/1-5-documenting-
and-reporting/#:~:text=Reporting%20is%20oral%20communication
%20between [Accessed 14 Nov. 2023].
hakeem-sampson (2014). PPT - Chapter 16 Nursing Documentation
PowerPoint Presentation, free download - ID:5972089. [online]
SlideServe. Available at: https://www.slideserve.com/hakeem-
sampson/chapter-16-nursing-documentation [Accessed 14 Nov.
2023].