DOCUMENTING AND REPORTING

Submitted by : Vargas, Alyza B.

Section: BSN-1A
Submitted to:Mrs, Remy Garcia.

6.1 Definition of Terms

A report is oral, written, or computer-based communication intended to convey information to
others. For instance, nurses always report on clients at the end of a hospital work shift.

A record is written or computer-based. The process of making an entry on a client record is

called recording, charting, or documenting.

6.2 Purposes of Client Records

6.2.1Communication. This prevents fragmentation, repetition, and delays in client care
6.2.2 Planning Client Care. Nurses use baseline and ongoing data to evaluate the
effectiveness of the nursing care plan.
6.2.3 Auditing Health Agencies. An audit is a review of client records for quality assurance
purposes.
6.2.4 Research The treatment plans for a number of clients with the same health problems can
yield information helpful in treating other clients.
6.2.5 Education. A record can frequently provide a comprehensive view of the client, the
illness, effective treatment strategies, and factors that affect the outcome of the illness.
6.2.6 Reimbursement. This is not only facilitates reimbursement from the federal government,
but also from insurance companies and other third-party payers.
6.2.7 Legal Documentation. The client's record is a legal document and is usually admissible
in court as evidence.
6.2.8 Health Care Analysis. Records can be used to establish the costs of various services
and to identify those services that cost the agency money and those that generate revenue.

Documentation Systems
6.3.1 Source-Oriented Record
The traditional client record is a source-oriented record. Each person or department makes
notations in a separate section or sections of the client's chart. For example, the admission
department has an admission sheet; the physician has a physician's order sheet, a physician's
history sheet, and
progress notes; nurses use the nurse's notes; and other departments or personnel have their
own records.

Narrative charting is a traditional part of the source oriented record. It consists of written notes
that include routine care, normal findings, and client problems.
6.3.2 Problem-Oriented Medical Record (POMR), established by Lawrence Weed in the
1960s, the data are arranged according tot the problems the client has rather than the source of
the information.

The advantage of POMR is that:

1. it encourages collaboration
2. the problem list in the front of the chart alerts caregivers to the client's needs and makes it
easier to tract the status of each problem

The disadvantages are that:

1. caregivers differ in their ability to use the required charting format
2. it is somewhat inefficient because assessment s and interventions that apply to more than
one problem must be repeated.

Four basic components of POMR

Database - it includes the nursing assessment, the physician's history, social and family data,
and the results of the physical examination and baseline diagnostic tests. Data are constantly
updated as the client's health status changes.
2. Problem list - problems are listed in the order in which they are identified, and the list is
continually updated as new problems are identified and others resolved.
3. Plan of care - physician write physician's orders or medical care plans;nurses write nursing
orders or nursing care plans.
4. 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.
Progress notes are numbered to correspond to the problems on the problem list and may be
lettered for the type of data. For example, the SOAP format is frequently used. SOAP is
acronym for subjective data, objective data, assessment, and planning.

S - Subjective data consist of information obtained from what the client says. It describes the
client's perceptions of and experience with the problem. Subjective data are included only when
it is important and relevant to the problem.
O - Objective data consist of information that is measured or observed by use of the senses
(e.g., vital signs, laboratory and x-ray results)
A - Assessment is the interpretation or conclusions drawn about the subjective and objective
data.
P - The plan is the plan of care designed to resolve the stated problem

Over the years, the SOAP format has been modified. The acronyms SOAPIE and SOAPIER
refer to formats that add interventions, evaluation and revision.

I - Intervention refer to the specific interventions that have actually been performed by the
caregiver.
E - Evaluation includes the client responses to nursing
interventions and medical treatments. This is primarily reassessment data.
R - Revision. Cha ee maye mode in desire sucoted by theinterventions, or target dates.

6.3.3 PIE
The PIE documentation model groups information into three categories. PIE is an acronym for
problem, intervention and evaluation of nursing care.

6.3.4 Focus Charting

Focus charting is intended to make the client and the client concerns and strengths the focus
of care. Three columns for recording are usually used: date and time, focus, progress notes.
The focus maybe a condition, a nursing diagnosis, a behavior, a sign or symptom, an acute
change in the client's condition, or a client strength. The progress notes are organized into:

1. (D) Data
Data category reflects the assessment phase of the nursing process and consist of observations
of client status akd behaviors including data flow sheets.
2. (A) Action
The action category reflects planning and implementation and includes immediate and future
nursing actions. It may also include any changes to the plan of care.
3. (R) Response
The response category reflects the evaluation phase of the nursing process and describes the
client's response to any nursing and medical care

6.3.5 Charting by Exception

Charting by Exception (CEB) is a documentation system in which only abnormal or significant
findings or exceptions to norms are recorded.

CBE incorporates three key elements:

1. Flow sheet. Examples of flow sheets include a graphic record, fluid balance record, daily
care record, client teaching record,
client
discharge record, and skin assessment record.
2. Standards of nursing care. An agency using CBE must develop its own specific standards
of nursing practice that identify the minimum criteria for client care regardless of clinical area.
3. Bedside access to chart forms. In the CBE system, all flow sheets are kept at the client's
bedside to allow immediate recording and to eliminate the need to transcribe data from the
nurse's worksheet to the permanent record.

6.3.6 Computerized Documentation

Computerized clinical record system are being developed as a way to manage the huge volume
of information required in contemporary health care. Computers make care planning and
documentation relatively easy.

6.3.7 Case Management

The case management model emphasizes quality, cost-effective care delivered within an
established length of stay. This model uses a
multidisciplinary approach to planning and documenting client care, using critical pathways.
These forms identify the outcomes that certain groups of clients are expected to achieve on
each day of care, along with the interventions necessary for each day.

Along with critical pathways, the case management model incorporates graphics and flow
sheets. Progress notes typically use some type of charting by exception. For example, if goals
are met, no further charting is required.
A goal that is not met is called a variance. Variations are deviations to what is planned on the
critical pathway - unexpected occurrences that affect the planned care or the client's responses
to care.

6.4 Reporting
The purpose of reporting is to comunicate specific information to a person or group of people. A
report wehter oral or writte, should be concise including pertinent information but no extraneous
detail

Examples:
6.4.1 Change-of-Shift-Reports
A change-of-shift-report is a report given to all nurses on the next shift.

6.4.2 Telephone Report

The nurse receiving a telephone report should document the date and time, the name of the
person giving the information, and the subject of the
information received and signs the notation. Telephone reports usually include the client's name
and medical diagnosis, change in nursing assessment, vital signs related to baseline vital signs,
significant laboratory data, and related nursing interventions.

6.4.3 Telephone Orders

Physician often order a therapy (e.g., a medication) for a client by [Link] agencies
have specific policies about telephone orders. Many agencies allow only registered nurses to
take telephone orders.

While the physician gives the order, write it down and repeat it back to the physician to ensure
accuracy. Question the physician about any order that is ambiguous, unusual (e.g., an
abnormally high dosage of a medication), or contraindicated by the client's condition.

6.4.4 Care Plan Conference

A care plan conference is a meeting of a group of nurses to discuss possible solutions to
certain problems of a client,
such as inability to cope with an
event or lack of progress toward goal attainment.
6.4.5 Nursing Rounds
During round, the nurse assigned to the client provides a brief summary of the client's nursing
needs and the interventions being implemented.