RECORDING & REPORTING

Anil Kumar BRLecturer

Medical surgical nursing

Introduction

■ Documentation within a client’s medical record is a vital aspect of nursing care or practice.

■ The nursing documentation must be accurate, comprehensive,and flexible.

■ Information in the client records provides a detailed account of the level of quality of nursing care delivered to client’s. And

■ Accurate and effective documentation ensures continuity of care, saves time and prevent duplication or error in the patient care.

Purposes And importance of Records A record is permanent written communication that documents information relevant to a client’s health care management.

Purposes or importance of records■ Communication■ Legal documentation■ Nursing audit■ Educational( records are useful in educational

purposes in various ways e.g a client diagnosis,s/s of disease,sucessful and unsuccessful diagnostic findings,and client behaviours.)

Purposes and importance of records■ Financial billing■ Nursing research■ Improve quality of nursing care■ Prevent errors and duplication and ■ Planning of care

Principles or guidelines for quality documentation and recording■ Nurses are need high-quality

documentation and recording are essential to enhance effective , accurate and individualized patient care.

■Quality documentation and recording have several important characteristics.

Principles and guidelines for quality documentation and recording.........■ Factual■ Accurate■ Completness■ Current■ Organized■ Timings

Factual.........

■ A factual record contains descriptive, objective information about what a nurse sees,hears,fells,and Smell’s.

■ E.g. A client BP is 80/50 mmHg, client diaphoretic,restlesness, and HR is 102 and regular.*(the use of inferences client appears to be in shock)

■ Without supporting factual data is not acceptable because it can be misunderstood.

Accurate.......

■ The use if exact measurements establishes accuracy.

■ Use of an institution accepted abbreviations,symbols and system of measures.

Completness......

■ The information will not be completed without full information.

■ The information within a record entry or a report needs to be complete, containing appropriate and vital information otherwise it’s considered incomplete.

Current.......

■ Timely documentation and recording is an vital principles in documentation.

■ To increase accuracy , quality of care and decrease unnecessary duplication and preventing errors it’s essential to record timely.

■ For e.g a client BP is 140/90 when you’re admission of some type of drugs the nude should records same.

Organized......

■ As a nurse you want communicate information in a logical order.

■ For e.g an organized note describes the client’s knowledge deficit, nurses assessment and interventions, and the client’s response.

■ The nurse should applying theories, critical thinking, EBP, and the nursing process gives logic and order to nursing documentation.

Methods Of recording and documentation■ There are various documentation methods

for recording client’s data.■ Each nursing services selected a

documentation system that reflects the philosophy if the instructions.

Methods of recording and documentation■ Narrative documentation■ Problem oriented medical record (POMR) 1. Data base 2. Problem list 3. Nursing care plan 4. Progress notes (This are Major section of POMR)

Methods of recording and documentation . Continue......■ Source records■ Charting by exception ( CBR)■ Case management plan and critical

pathways

Narrative documentation.....

■ It’s most common traditional method for recording and documentation of nursing care.

■ It’s simple method■ Use of a storyline format

Example for narrative notes

Problem oriented medical record ( POMR)■ The POMR is a method of documentation

that emphasize the client’s problems.■ Data are organized by problem or diagnosis■ Basically each member if the health care

team contributes to a single list of identified client problems.

The POMR Sections

■ DATA BASE (e.g all available assessment information pertaining to the client such as history &physical assessment, nutrition assessment, nurse’s admission history, ongoing assessment and laboratory reports etc)

■ The data base is foundation for identifying client problems and planning of care.

The POMR Sections

■ PROBLEM LIST......A) After analyzing data, health care team members

identify problems and make a single problem listB) The problem list includes the client’s both

physiological, psychological,sicual , cultural,spirtual,developmental,and environmental needs.

Nursing care plans....

Develop a care plan for each problem■Nurses document the plan of care in variety

of formats■ Generally these plans of care include

nursing diagnosis,outcomes,and interventions.

Progress notes....

■ Health care team members monitor and recorded the progress of a client’s problems.

■ Progress notes come in different formats or structured notes.

Progress notes ... Continue...

■ One method formerly known as “ SOAP” stands for

S – Subjective data O – Objective data A – Assessment P - plan

Continue...

■ A second progress note method is the PIE format.

■ It’s similar to SOAP charting in its problem oriented nature.

P – Problem I – Interventions E - Evaluation

Continue...

A third narrative format is focus is charting.1) It involves use of DAR....... D – Data ( subj &obj) A- Action or Nursing interventions R- Response of the client *effectiveness

Source of records

■In a Source record the client has a separate for each discipline e.g nursing, medicine,social work or respiratory therapy to record data.

■ One advantage of a source record is that caregivers can easily locate the proper section of the record in which to make entries.

■ A disadvantage of this method is that details a specific problem are distributed through out the record.

Example for disadvantage of source records■ A nurse describes the character of abdominal

pain and use if non pharmacologic therapy such as relaxation therapy and analgesic medications in the nurse’s notes.

■ The physician’s notes describe the progress of the client’s bowel obstruction and the plan for surgery in separate section of the record for same client.

Charting by exception.... CBE

■ CBE focuses on documenting deviations from the established norm or abnormal findings.

■ This approach reduces documentation time and highlights trends .

Case management plan and critical pathways....■ The case management model of delivering

care in corporates a multidisciplinary approach to documenting client care.

Jai hind .....jai Karnataka