Documentation and Reporting

Ns. Mukhamad Fathoni, S.Kep., MNS Jurusan Keperawatan, Fakultas Kedokteran Universitas Brawijaya Email : mfathony@yahoo.com

INTRODUCTION
A good nurse needs to have great reporting skills. Since it takes time to develop great reporting skills, you should work on this area if you're trying to land a job as a clinical nurse or manager.

Documentation as Communication
Communication is a dynamic, continuous, and multidimensional process for sharing information. Reporting and recording are the major communication techniques used by health care providers.

Documentation as Communication
The medical record serves as a legal document for recording all client activities by health care practitioners. Documentation is defined as written evidence of:
The interactions between and among health professionals, clients, their families, and health care organizations The administration of tests, procedures, treatments, and client education The results or clients response to these diagnostic tests and interventions

Documentation as Communication
Nurses rely on charting, records, and systems that support the implementation of the nursing process. Systematic documentation is critical to presenting the care administered by nurses in a logical fashion. Critical thinking skills, judgments, and evaluation must be clearly communicated through proper documentation

Purposes of Health Care Documentation

Professional Responsibility and Accountability Communication Education Research Legal and Practice Standards Recording provides written evidence of what was done for the client, the clients response, and any revisions made in the care plan

Purposes of Health Care Documentation

Recording documents compliance with professional practice standards and accreditation criteria. Written records are a resource for review, audit, reimbursement, and research. Documentation provides a written legal record to protect the client, institution and practitioner.

Purposes of Health Care Documentation

Education
Health care students use the medical record as a tool to learn about disease processes, diagnoses, complications, and interventions. Clinical rounds and case conferences rely heavily on information contained in the medical record.

Purposes of Health Care Documentation

Research
Researchers rely heavily on medical records as a source of clinical data. Documentation can validate the need for research.

Purposes of Health Care Documentation

Legal and Practice Standards
In 80% to 85% of malpractice lawsuits involving client care, the medical record is the determining factor in providing proof of significant events.

Legal and Practice Standards

Informed Consent Advance Directives Indonesian National Nurses Association (INNA) Standards of Care State Nurse Practice Acts

Legal and Practice Standards

Informed consent means that the client understands the reasons and risks of the proposed intervention. Witnessing confirms that the person who signs the consent is competent.

Principles of Effective Documentation

Nursing notes must be logical, focused, and relevant to care, and must represent each phase of the nursing process. Nursing documentation based on the nursing process facilitates effective care.

Elements of Effective Documentation

Use of Common Vocabulary Legibility Abbreviations and Symbols Organization Accuracy Documenting a Medication Error Confidentiality

Elements of Effective Documentation

Use of Common Vocabulary
Enhances the quality of documentation. Supports the efforts of research. Improves communication and lessens the chance of misunderstanding between members of the health team.

Elements of Effective Documentation

Legibility
Print if necessary. Do not erase or obliterate writing. Draw one line through an erroneous entry. State the reason for the error. Sign and date the correction.

Elements of Effective Documentation

Correcting a documentation error

Elements of Effective Documentation

Abbreviations and Symbols
Always refer to the facilitys approved listing. Avoid abbreviations that can be misunderstood.

Elements of Effective Documentation

Organization
Start every entry with the date and time. Chart in chronological order. Chart in a timely fashion to avoid omissions. Chart medications immediately after administration. Sign your name after each entry.

Elements of Effective Documentation

Charting a late entry

Elements of Effective Documentation

Charting a prn medication

Elements of Effective Documentation

Accuracy
Use factual, descriptive terms to chart exactly what was observed or done. Use correct spelling and grammar. Write complete sentences. Maintain continuity of care by recording with respect to notes made on previous shifts.

Elements of Effective Documentation

Documenting a Medication Error
Chart the medication on the MAR. Document in the nurses progress notes:
Name and dosage of the medication Name of the practitioner who was notified of the error Time of the notification Nursing interventions or medical treatment Clients response to treatment

Elements of Effective Documentation

Confidentiality
The nurse is responsible for protecting the privacy and confidentiality of client interactions, assessments, and care. The clients significant others, insurance companies, or other parties not directly involved in care provided by the health team may not have access to clients records.

Methods of Documentation
Narrative Charting Source-Oriented Charting Problem-Oriented Charting PIE Charting Focus Charting Charting by Exception (CBE) Computerized Documentation Case Management with Critical Paths

Methods of Documentation
Narrative Charting
Describes the clients status, interventions and treatments; response to treatments is in story format. Narrative charting is now being replaced by other formats.

Methods of Documentation
Source-Oriented Charting
Narrative recording by each member (source) of the health care team on separate records.

Methods of Documentation
Problem-Oriented Charting (POMR)
Uses a structured, logical format called S.O.A.P.
S: subjective data O: objective data A: assessment (conclusion stated in form of nursing diagnoses or client problems) P: plan

Problem-Oriented Charting (POMR)

Uses flow sheets to record routine care. A discharge summary addresses each problem. SOAP entries are usually made at least every 24 hours on any unresolved problem. SOAP was developed on a medical model.

Problem-Oriented Charting (POMR)

SOAPIE and SOAPIER refer to formats that add:
I: Intervention E: Evaluation R: Revision

Problem-Oriented Charting (POMR)

Methods of Documentation
PIE Charting
P: Problem I: Intervention E: Evaluation

Key components are assessment flow sheets and the nurses progress notes with an integrated plan of care. PIE charting is a nursing model.

Methods of Documentation

Methods of Documentation
Focus Charting
A method of identifying and organizing the narrative documentation of all client concerns. Includes data, action, response. Uses a columnar format within the progress notes to distinguish the entry from other recordings in the narrative notes.

Methods of Documentation
Charting by Exception (CBE)
The nurse documents only deviations from preestablished norms. Avoids lengthy, repetitive notes. Enables the identification of trends in client status.

Methods of Documentation
Computerized Documentation
Increases the quality of documentation and save time. Increases legibility and accuracy. Enhances implementation of the nursing process. Enhances the systematic approach to client care. Provides clear, decisive, and concise key words (standardized nursing terminology).

Methods of Documentation
Computerized Documentation
Provides access to other data, enhancing critical thinking. Information is quickly coordinated and integrated by other departments. Facilitates statistical analysis of data.

Methods of Documentation
Point-of-Care System
A handheld portable computer is used for inputting and retrieving client data at the bedside. Provides each health care practitioner with all pertinent client data to ensure continuity of care without duplication. Provides crucial client information in a timely fashion.

Methods of Documentation
Case Management Process
A methodology for organizing client care through an illness, using a critical pathway. A critical pathway is a monitoring and documentation tool used to ensure that interventions are performed on time and that client outcomes are achieved on time.

Forms for Recording Data

Kardex Flow Sheets Nurses Progress Notes Discharge Summary

Forms for Recording Data

The Kardex is used as a reference throughout the shift and during change-ofshift reports.
Client data Medical diagnoses and nursing diagnoses Medical orders Activities

Forms for Recording Data

Flow sheets reduce the redundancy of charting in the nurses progress notes. The information on flow sheets can be formatted to meet the specific needs of the client.

Forms for Recording Data

Nurses progress notes are used to document the clients condition, problems and complaints, interventions, responses, achievement of outcomes. Progress notes can be completely narrative or incorporated into a standardized flow sheet.

Forms for Recording Data

Discharge Summary
Clients status at admission and discharge Brief summary of clients care Interventions and education outcomes Resolved problems and continuing need Referrals Client instructions

Trends in Documentation
Standardized data bases are required to ensure accuracy and precision in nursing information systems.

Trends in Documentation
Nursing Minimum Data Set (NMDS) Nursing Diagnoses (Taxonomy II) Nursing Intervention Classification (NIC) Nursing Outcomes Classification (NOC)

Reporting
Report: Is oral, written, or computer- based communication intended to convey information to others. Record: Is written or computer based, the process of making an entry on a clients record is called recording, charting, or documenting. A clinical record, also called a chart or client record is a formal, legal document that provides evidence of a clients care.

Reporting
Verbal communication of data regarding the clients health status, needs, treatments, outcomes, and responses Summary of current critical information to facilitate clinical decision making and continuity of client care

Reporting
Reporting is based on the nursing process, standards of care, and legal and ethical principles. Reports require participation from everyone present.

Reporting
Summary Reports Walking Rounds Telephone Reports and Orders Incident Reports

Reporting Skills In Nursing

Be Prepared Don't Be Afraid of Silences Be Prepared, But Not Rigid

Summary Reports
Commonly occur at change of shift (or when client is transferred).
Assessment data Primary medical and nursing diagnoses Recent changes in condition, adjustments in plan of care, and progress toward expected outcomes Client or family complaints

Walking Rounds
Nursing, physician, interdisciplinary Occur in the clients room and include the client

Telephone Reports and Orders

Report transfers, communicate referrals, obtain client data, solve problems, inform a physician and/or clients family members regarding a change in the clients condition. Telephone orders are documented in the nurses progress notes and the physician order sheet.

Documenting a Telephone Order

Incident Reports
Used to document any unusual occurrence or accident in the delivery of client care. The incident report is not part of the medical record, but it may be used later in litigation.

LETS PRACTICE!!
Divide your class into 10 small groups Each group must present CASES of patients in different areas Grup 1 : fractures Grup 2 : Infectious disease Grup 3 : Pediatric patient Grup 4 : Gerontology patient Grup 5 : pregnant woman in labour Grup 6 : emergency patient in hospital settings Grup 7 : emergency patient in pre hospital settings Grup 8 : discharged patient Grup 9 : mental health patient Grup 10 : dead patient Each individual of the groups should prepare their own cases of maximum 5 minutes reporting

LETS PRACTICE!!
In the next 2x50, report your work in your group by role play.
Make a pair in your group. One does the reporting and the other does note taking Change the turn. Discuss in pair.

REFERENCE
Lhynnely. (2012). Nursing Abbreviations [Electronic Version]. Retrieved June 4, 2012, from http://nursingcrib.com/nursingnotes-reviewer/fundamentals-ofnursing/nursing-abbreviations/ Kozier, E.2008. Fundamental of Nursing. 5th Edition. Lippincott: William Wilkins

Questions? Comments?