DOCUMENTATION

Prof.Rosamma Joseph
T JOHN COLLEGE OF NURSING
DOCUMENTATION

• Documentation- is the recording of information relevant

to assessment, planning, implementation and
evaluation.
Client record

• Is the written, legal record of all pertinent interactions with the client
– assessing, diagnosing, planning, implementing and evaluating.
• Is a formal, legal document that provides evidence of a client’s care.
• Is the compilation of a client’s health information.
• Is a brief account of personal and medical history of the client, results
of the diagnostic test, findings of medical examination, treatment and
nursing care, daily progress notes and advice on discharge.
Purposes of documentation
• Communication- among healthcare professionals to promote
continuity of care.

• Prevents fragmentation, repetition and delay in client care.

• Planning client care – eg- a physician may start antibiotics after

noting a rise in client’s temperature.

• Nurses use data from client record to prepare nursing care plan.

• Legal accountability – may be used in court proceedings.

• Education- records are used as educational tool.
• Nursing and medical students use it
• Research- data from record is valuable resource for research.
• Reimbursement – for insurance , reimbursement of medical costs,the
bills and data need to be submitted.
• Quality assurance – auditing of the records are done for quality
assurance.
• Healthcare analysis – information from the records are used to
identify agency needs; to establish the cost of various services and
identify those services that add to the expenses and those that
generate revenue.
DOCUMENTATION SYSTEMS
• SOURCE ORIENTED RECORDS
• PROBLEM ORIENTED MEDICAL RECORD
• Traditional client record is source oriented.
• Each person or department makes notations in separate sections of the
record.
• Admission department- admission sheet, physician- history and physical
examination record, progress notes, medication orders, nurses- nurse’s
record.
• About same problem different health care team members will record in
different sections.
• Advantages of source oriented medical record
• Convenient- easy to locate the information
• Easy to record the information by all categories
• Disadvantage
• Information about a particular problem is scattered throughout the
chart
Problem-oriented medical record (POMR)
• Lawrence Weed, 1960
• Data are arranged according to the problems the client has, rather
than source of information.
• 4 basic components
1. Data base
2. Problem list
3. Plan of care
4. Progress notes.
• Data base- consist of all information known about the client when the
client first enters the healthcare agency.
• Includes the nursing assessment, physician history, social and family data
and results of physical examination and basic diagnostic tests.
• Problem list – derived from the data base.
• Kept at the front of the chart.
• Problems are listed in order of identification. And is continually updated
as new problems are identified and old ones resolved.
• All caregivers contribute to the problem list.
• Plan of care- careplans are generated by the person who has identified
the problems. Physicians write physician’s orders and nurses write nursing
orders
• Progress notes- day to day condition of patient is recorded by all
METHODS OF CHARTING
1. NARRATIVE CHARTING- consist of written notes that include routine
care, normal findings and current problems.
2. CHARTING BY EXCEPTION (CBE)- only abnormal or significant
findings or exceptions to norms are charted.
3 key elements of CBE
3. Flow sheets- graphic record, fluid record (I/O chart), client teaching
record, daily care record.
4. Standards of nursing care- exceptions to standards of care will be
recorded.eg- if standard of care for unconscious patient is 4hrly oral
care, if not done will be narrated in detail.
5. Bedside access to charts- easily located.
BENEFITS- less charting time, timely charting
Narrative
charting
CHARTING BY EXCEPTION (CBE)-
3. FOCUS CHARTING- focus on a condition, problem, nursing diagnosis, a
behaviour or a client strength.
3 columns for charting -Date and time, focus and progress notes
DATE & FOCUS PROGRESS NOTES
TIME
6/11/20, Pain D-Guarding abdominal incision, facial
9.00am grimacing, pain-8/10
A- Administered Morphine4mg IV
R- rates pain at 1, willing to ambulate

-data, action, response- DAR format or DAE- Data, Action, Evaluation

4. PROBLEM FOCUSSED CHARTING
5. FACT SYSTEM-
F- individualized flow sheets
A- assessment sheets that are standardized
C- concise integrated progress notes
T- timely entries
6. CORE CHARTING- focus on nursing process. DAE- data, action,
evaluation
7. OUTCOME DOCUMENTATION- focus on client outcomes
Principles of documentation
• Must be consistent with professional and agency standards
• Accurate
• Concise
• Legible
• factual
• Organised
• Legally prudent
• Complete
• Sequence & timeliness
• Objectivity
• Prevention of loss
• Prevention of damage.
GUIDELINES FOR DOCUMENTATION
• Document date and time of each record.
• Organize the content according to date and
time.
• Timely record the data- not before or after.
• Maintain confidentiality of all records.
• If a mistake is made, draw a line through it
and write the words mistaken entry above
or next to it and enter your name. do not
erase or use correction ink. The original
entry must be visible.
• Make sure you are charting in the correct
record.
• Avoid spelling mistakes, grammar mistakes.
• Record only appropriate information.
• Write observations that the individual has seen,
heard, smelled or felt.
• Document all information necessary-
completeness.
• Each entry made should be followed by the
signature of the person who made the entry.
• Use accepted terminology-abbreviations,
symbols. D/C- can mean discharge or discontinue.
• All entries should be made with dark ink, which is
permanent. Follow guidelines of agency regarding
colour of ink to be used.
CARE OF
RECORDS
• Records are kept under safe custody.
• Do not separate individual sheets from the record.
• Records are kept in a place not accessible to all.
• Keep the confidentiality of records.
• Records are not handed over to anyone other than health team
members without written permission from administration.
• Handle records carefully.
• All records are identified with the biodata of the clients.
Care of records contd…………
• Records are never sent out of hospital without doctor’s permission.
• Records should be written clearly, concisely, accurately, appropriately
and legibly.
• Avoid overwriting. If any entries need to be corrected, cut it across
and write the new one and the one who made the correction should
sign there.
• All entries should be signed by the individual who writes them.
• Use only universally accepted abbreviations.
• Don’t leave any blank spaces in between. If any cross it and sign.
• In Each page make the entry of client’s name, age, bed no. and UHID
Number.
• Adequate number of filing cabinets and other equipments for storage
should be available
• Adequate stationery should be available.
• Records should be periodically audited.
• Standards should be framed for
record keeping.
• Clearly understand the purpose for
which the record is maintained.
• Records should be up to date.
• People who are responsible for record
maintenance should be aware of their
responsibility.
• There should be adequate, safe,
fireproof storage arrangements.
DON’T s IN DOCUMENTATION
DON’T ………………
• Leave blank space to chart later.
• Document for another person.
• Chart in advance.
• Use vague terms. Eg- a big wound.
• Alter a record even if asked by a superior.
• Record assumptions.
RECORD

• a thing constituting a piece of evidence about the past,

especially an account kept in writing or some other permanent
form.

• Is a permanent written communication that documents

information relevant to a client’s healthcare management.
Content for documentation
• Admission notes • Client teaching notes
• Change of shift notes • Symptoms and
• Assessment notes complaints
• Progress notes • Medications and
treatments
• Transfer and discharge
• Activities of daily living
notes
• Spiritual care
TYPES OF RECORDS
• ADMISSION FORM
• NURSE’S RECORD
• DOCTOR’S ORDER SHEET, PROGRESS NOTES
• MEDICATION CHART
• HISTORY & PHYSICAL EXAMINATION FORM
• GRAPHIC CHART, FLOW CHARTS
• DIET SHEETS
• LAB RECORD
• CONSENT FORM
• REFERRAL FORM
Flow sheets
• A flow sheet enables nurses to record data quickly and concisely and
provides an easy to read record of the client’s condition over time.
• Graphic record- typically indicates body temperature, pulse,
respiratory rate, blood pressure, weight etc.
• Fluid balance record (intake-output chart)- all routes of fluid intake
and output are measures and recorded on this form.
VITALS CHART
• Medication administration record-
• medication flow sheets usually include specially designated areas for
the date of medication order. The expiration date, medication name
and dose, frequency and time of administration and route and the
nurses’ signature.
• Skin assessment record-
• a skin or wound assessment is recorded on a flow sheet which record
stage of skin injury drainage, odor, culture information and
treatments.
REGISTERS
• admission & discharge,
• births &death,
• census,
• MLC,
• register for deliveries and surgeries,
• register for OPD Attendance,
• notifiable diseases,
• special treatments
Computerized documentation

• Nurses use computerized documentation for supplies,

equipment, stock medications and diagnostic testing.
ELECTRONIC MEDICAL RECORD
Advantages
• Speed in communication
• Accuracy of information
• Easy retrieval of information
• Can easily revise data
• Cost effective
• Saves documentation time
• Increases legibility
• Easy statistical analysis of data
Ensuring confidentiality of computer
records
• Have a personal password to enter and sign off. Don’t share your
password with any one else.
• After logging in, never leave computer terminal unattended.
• Don’t leave client information displayed on the monitor so that others
may see it.
• Shred all unneeded computer generated worksheets.
• In case of any entry error, follow the agency’s procedure.
• Follow agency’s procedure for entering sensitive information like
diagnosis of AIDS.
Disadvantages

• No privacy, if security measures are not used.

• System failure

• Expensive

• Extended training period when update is installed.

Nursing informatics
• Is the science of identifying, collecting, storing and processing
information.
• Is defined as a combination of computer science and nursing science
designed to assist in the management and processing of nursing data,
information and knowledge to support the practice of nursing and
the delivery of nursing care.
LET US REVISE
• What are the advantages of computerised documentation?
• What are the disadvantages of computerised documentation?
• How can you make computerised documentation better?
REPORT
• Is the verbal or written communication of data regarding the client’s
health status needs, treatments, outcomes and responses.
• a report must be appropriate, accurate, truthful, complete, clear,
concise and legible.
• Common methods of reporting include face to face meeting,
telephone conversations, written reports, computerized reports.
Objectives
• Tool of communication between members of health team.
• Will avoid duplication of work.
• Tell why a procedure is done or not done.
• Can plan the care without wasting time.
Change of shift reports
• Is the report given by the primary nurse to the nurse replacing her or
by the charge nurse to the nurse who assumes responsibility for
continuing care of the client.
• Information shared includes:
• Identification data
• Current health status of the client
• Current orders: nurse’s orders and physician’s orders
• Report of clients who have been transferred or discharged.
• Summary of care of new clients
Change of shift reports
• Report among members of the nursing team. Each member of the
team gives a detailed report to the team leader either at the end of
the day’s work or whenever she leaves the ward. A report is given at
any time when the responsibility for the client care is turned over
from one person to another.
Report between head nurse and her assistant
• Whenever head nurse is not present, the assistant has to take over
the supervision of the client care. To facilitate this easily, the head
nurse keeps on giving information about condition of all clients,
treatments they are receiving, observations that are to be made,
problems of staffing and plans to meet them, expected admissions,
discharges, treatment and changes in the routines of the ward.
• When head nurse returns after her absence, the assistant nurse
reports back to the head nurse all changes in the situation that
happened during her absence.
Reports to the physician

• The nurse reports to the doctor any unusual

Changes happening to the client, results of any medications or
treatments carried out for the clients.
Report on mistakes, accidents and
complaints
• INCIDENT REPORT-

• Writing a detailed report of mistakes or accidents that

happened in client care and complaints made by the
client or visitors to the authority is helpful to prevent
similar incidents in the future.
Incident report
• It is the documentation of anything out of the ordinary that results in
or has the potential to harm a client, employee or visitor.
• It can be used for quality improvement.
Purposes of incident report
What to report?
• Accidents, injuries, falls- patient or visitor
• Improper administration of medications
• Administration of wrong medications.
• Exposure of skin, eye, mucous membrane or parenteral
to potentially infectious materials due to action by health
care worker.
• Medication reaction
• Property damage / missing articles.
Evaluation reports
• Monthly evaluation reports of students are sent to the principal of the
school or college of nursing by the head nurses.
• Performance evaluation report of the staff are sent by head nurse to
nursing superintendent.
 . Telephone reports

• The nurses receiving the telephonic report should document the date,
tome and name of the person giving the information and what
information was given, along with the signature.
• If there is any doubt about the information given, repeat it back to the
person to ensure accuracy.
• When physician gives a telephonic order, it must be written down at
that time and repeated back to the physician for accuracy.
record and report

•  record is an item of information put into a temporary or

permanent physical medium

•  while report is a piece of information describing, or an account

of certain events given or presented to someone.
Progress note
• When caring for patients, medical professionals write
nursing progress notes in order to keep a record of their
patient's recovery and care.
• These notes include important information about the
patient.
Elements to include in a nursing progress note

• Date and time of the report

• Patient's name
• Doctor and nurse's name
• General description of the patient
• Reason for the visit
• Vital signs and initial health assessment
• Results of any tests or bloodwork
• Diagnosis and care plan
• Patient's response to care
• Instructions for further care
• Additional observations
UNIT VI- DOCUMENTATION AND REPORTING
SHORT ANSWERS
1.List down types of records in 1. What is progress note
hospital 2. State four guidelines for
2.What is incidental report recording
3. What is the meaning of
3.Differentiate record & report
documentation
4.State four guidelines for reporting 4. What is the meaning of
5.What is transfer report computerized documentation
5. List the cases to be included
under medico legal records