Documentation, Recording, Reporting and Communication

Objectives:
Up on completion of this lesson, the student will be able to:-
1. Define the documentation.
2. Mention the purposes of documentation.
3. Identify the standards of documentation
4. Explain the deficiencies of documentation
5. Discuss principles of documentation.
6. Define the reporting.
7. Differentiate between different forms of reporting
8. Enumerate the nurses responsibility for record keeping.
9. Define communication
10. Describe organizational communication and skills in the workplace
11. Describe communication skills in the workplace
12. Identify barriers to communication and strategies to overcome them
13. Identify strategies to overcome the barriers to communication

Outlines:
1. Introduction
2. Definition the documentation
3. The purposes of documentation.
4. Standards of documentation
5. Documentation deficiencies
6. Principles of documentation.
7. Problem Areas of Documentation
8. Reporting Forms
▪ Incident Reports
▪ Telephone Reports and Orders :
▪ Handoff

9. The nurses' responsibility for record keeping.

10. Definition of communication
11. Organizational communication in the workplace
12. Communication skills in the workplace
13. Barriers to communication
14. Strategies to overcome the barriers to communication
 Documentation, recording, reporting and communication

Documentation

Introduction:
Documentation system is a necessary activity and be an integral part of
nursing practice and professional patient care rather than something that takes
away from patient care. Documentation is not optional.

Definition of documentation:
Documentation is defined as a written or electronically evidence of the interaction
between and among health professionals, clients, their families, and health care
organizations.
• The written legal records of all interventions with the client (assessment,
diagnosis, plan, implementation and evaluation)

Purposes of documentation:
1. Accountability
▪ Care providers are responsible and accountable for their own practice
2. Legal implications
▪ Was the care provided competent and safe, did it meet acceptable standards,
and was it timely and consistent with the employing agency or facility’s
policies?
▪ Is the care provided and documented consistent with the standards and
competencies?
▪ A chart or client record is one of the main documents of evidence.
3. To promote good nursing care
▪ Documentation encourages nurses to assess client`s progress and determine
which interventions are effective and which are ineffective, and identify
changes to the plan of care as needed.
▪ Documentation can be a valuable source of data for making decisions about
patient`s condition, all of which have the potential to improve the quality of
nursing practice and client care.
4. Coordination of care through
▪ Plan interventions
▪ Decision making about ongoing interventions
▪ Evaluation of patient's progress
5. Providing quality improvement and risk management
▪ Accurate documentation provides a way to measure and improve health
services and client outcomes.
▪ The documentation is used to manage risks in a health care setting and is
investigated if adverse events occur. improvement processes to evaluate
services provided and outcomes achieved.
6. Quality assurance monitoring
▪ When the care described in the clinical record doesn't meet an established
indicator of care, the quality committee decides what action to take to correct
the problem
7. Facilitating evidence-based practice:
▪ The health-care record provides a rich source of information related to nursing
interventions and evaluation of client outcome that are important source of
data for nursing and health research .
8. Research
▪ Documentation supply data for a study to determine validity of nursing
diagnosis. These research studies can then lead to improved documentation
9. Education
▪ Clinical manifestations
▪ Effective treatment modalities
▪ Factors affecting patient goal achievement
10. To meet professional and legal standards
▪ The nurse’s documentation may be used as evidence in legal proceedings such
as a court in which the client’s health record serves as the legal record of the
care or service provided.

Standards of Documentation
1. Client focused
– the documentation should be about the client and this includes the extension
of his family or someone who is legally named if there is no family.
2. Relevant
- Does a nurse chart events that are relevant to a particular client’s care and
progress?
- Does a nurse document the most important details?
3. Confidential
- Does a nurse and other care providers are bound by law to respect client
confidentiality.
- Does a nurse and other care providers leave paper-based charts open and the
computer screen exposed and visible for others to view?
- Does a nurse have organizational policies and are aware of legislation on client
confidentiality?
4. Clear, concise and comprehensive
- These are the 3Cs of accurate documentation.
- Is Does a nurse and other care providers hand writing clear and legible?
- How does a nurse and other care providers’ grammar and expressions of client care
to enable others to understand what have been written?
5. Permanent and retrievable
- A nurse and other care providers’ needs to remember that client notes become a
permanent and retrievable health record.
- These could be retrieved several months or years later by a lawyer for examination.
6. Accurate
- One of the most common deficiencies in documentation is accuracy of missing
details. Lack of significant detail is also the most highly criticized in the legal process
7. Chronological and timely
- It is important to document in order of occurrence and chart contemporaneously (as
soon as possible after the event or care).
- This can be extremely demanding for a health care provider who is caring for several
clients with complex and multiple health issues.
- Does a nurse endeavor to document as soon as possible after a care event?
8. Record of care
- Documentation must include assessments, perhaps planning, implementation or
interventions and evaluation or results of client events or ones that involve their
families).
Documentation Deficiencies
1. Illegible writing – One of the most common complaints in written
documentation is that of illegible or messy handwriting.
2. Signature – When a client notes are completed, your signature should be in a
written format and not printed. A cursive signature is much more difficult to
reproduce or falsify than a printed signature.
3. Failing to record pertinent health or medication information – Remember
that past health related experiences or medications prescribed assist the health
care team to make the best possible choices for a quick and speedy recovery if
that is possible.
4. Failing to record nursing actions –Although most health providers are diligent
and competent in client care activities, the legal system views undocumented
care as “not done”.
5. Failing to record medications given – This can have drastic consequences, as a
client could inadvertently receive another dose of medication which may be
injurious or life threatening.
6. Failing to document a discontinued medication or treatment – A client could
continue to receive a medication or treatment that is damaging or injurious.
7. Recording on the incorrect health record – This happens frequently and may
not be discovered until the next shift. In the meantime, a client could receive
incorrect or no care. A chart or patient record that has recording of another
client’s care raises suspicion in the legal system. The competency of the
caregiver who has charted on the incorrect patient is then in question.
8. Failing to record medication reactions – If a client has a serious allergic
reaction to a medication and is given it again, this could cause serious injury or
even death. All reactions, no matter how minor, should be documented.
9. Not providing adequate detail of changes in the client’s condition – a nurse
must work on finding a balance between excessive wordiness and necessary
client details. Missing details have often been cited in lawsuits and this reflects
on inadequate or incorrect care.
10. Transcribing orders incorrectly or transcribing inaccurate orders – Special
precautions must be taken with telephone orders. Numbers and doses must be
repeated back to the health professional issuing client orders. This repetition
may need to be done more than once in the interests of client safety.
 11. Incomplete records – If pages or specific forms of a client record are missing,
this raises suspicion in the legal system and may give evidence of poor care.
Removing pages from a client’s record is an illegal activity.

Principles of documentation:
- Document in the correct client chart or record.
- Write neatly and legibly and in ink.
- Use correct spelling and grammar.
- Document in chronological order promptly.
- Errors or late entries are to be corrected according to your employing agency or
facility’s policies and procedures.
- Sign correctly. Include a nurse name and designation and there should be no
blank spaces after or before her name or designation.
- Identify the individual by name and designation, unless this is contrary to the
employing agency or facility’s policies and procedures.
- Maintain client confidentiality at all times.
- Remember to write “not applicable” when using pre-printed client or hospital
forms

Problem Areas of Documentation

1. Not recording at the time of the event – long delays in documentation create
negative impressions of the care provider; flow sheets can be used to assist in
documentation of events.
2. Recording someone else’s actions – a nurse should record only what she had
saw, heard or did.
3. Recording out of chronological order – this is confusing to understand the care
provided; a nurse need to be careful with late entries.
4. Not recording concisely, factually, and clearly – has a nurse provided
significant details on client care and adverse events? Is here /his documentation
objective? Is here /his writing legible?
5. Recording infrequently – recording is to be done promptly with the changing
condition of the client and according to facility or agency policy; frequent
 documentation prevents charges that nothing was done or inadequate care was
provided.
6. Not recording corrections clearly – these need to be timely, honest and
forthright and according to employer policies and procedures.
7. Recording inaccurately and incompletely – the client record should contain
assessments, identification of health issues, plan of care, implementation of
care and the evaluation of care. Remember that time and details matter.
8. Facility or agency policies that are not realistic – a care provider may need to
address these with administration or management if documentation or other
polices relating to documentation are not realistic or require updating.

Reporting

Reporting Forms
1- Incidents report
Incident: It is an unplanned event within the scope of this procedure that causes, or
has the potential to cause, an injury or illness and damage to equipment, buildings,
plant or the natural environment.

➢ Who should report incidence report?

1. Only people who witness the incident should fill out and sign the incident
report.
2. Document the incident as it occurred; “Incident Report Completed” should
never appear in the patient’s record.

Purpose of the incident report is to

o Document the exact details of the occurrence while they are fresh in the minds
of those who witnessed the event.
o This information may be useful in the future when dealing with liability issues
stemming from the incident.
Examples of Risk
o Medication errors
o Complications from diagnostic or treatment procedures
o Medical-legal incidents
o Patient or family dissatisfaction with care
o Refusal of treatment or refusal to sign consent for treatment
Types of Incident
There are mainly three types of incidents
o Near Miss
o Adverse Events
o Sentinel Events
1. NEAR MISS:
o NEAR MISS incident did not result in harm, loss or damage.
o NEAR MISS may be clinical or non-clinical.
o Near miss reporting is just as important in highlighting weaknesses
in systems, policies/procedures and practices.
o If near misses are reported and learnt from and any necessary
corrective action taken, they can help to prevent actual incidents of
harm, loss or damage from occurring.
o Near miss should be reported with in 24hrs of working days
2. Adverse Incident (Clinical):
o An event or circumstance arising during clinical care of a patient
that could have or did lead to unintended or unexpected harm’.
o Adverse Incident (Non-Clinical) :- ‘An event or circumstance that
could have or did cause unexpected or unwanted harm, loss or
damage to any individual(s) involved (including patients but not
related to clinical care, staff, visitors etc) or damage to/loss of
property/ premises in the hospital .
o It should be reported within 2 hrs
3. Sentinal Events
o Unanticipated event that results in death or serious physical or
psychological injury to a patient and is not related to the natural course
of the patient’s illness.
o It should be reported immediately
Steps of incident reports:
a. Discovery: nurses may report actual or potential risk.
b. Notification: the risk manager receives the completed incident from nurses within
24 hours after the incident. A telephone call may be made earlier to hasten follow
up in the event of a major incident.
c. Investigation: The risk manager investigates the incident immediately.
d. Consultation: The risk manager consults with the referring physician, risk
management members to obtain additional information and guidance.
e. Action: The risk manager should clarify misinformation to the patient or family,
explaining exactly what happened
f. Recording: The risk manager should be sure that all records, including incident
reports, follow- up and actions taken, if any are filed in a central depository.

2.Telephone Reports and Orders:

▪ 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.
▪ Telephone orders are documented in the nurses’ progress notes and the
physician order sheet

3.Handoff
▪ The transfer of information (along with responsibility) during a transition in
care across the continuum for the purpose of ensuring the continuity and
safety of the patient’s care

Nurses responsibility for record keeping:

1- Keep under safe responsibility of nurses.
2- No individual sheet should be separated.
3- Not accessible to patients and visitors.
4- Strangers are not permitted to read records.
5- Never sent outside the hospital without written permission from administration.
6- Records are not handed to legal advisors without written permission from
administration.