Documentation and reporting

in Nursing

Edit by : Mohammad Swity

Suliman Al-obyat

Supervised by : Continuous Education

 Outlines

• Introduction.
• Definitions.
• Nursing Documentation and Nursing Process.
• Purposes of Documentation.
• Categories of Documentation Forms in Clinical
Record System.
• Contents of a Clinical Record.
• Principles of Recording.
• Principles reporting. 2
 Objectives
• After this lecture the nurse will be able to:
• Identify the meaning and purpose of
documentation and reporting .
• Determine the appropriate time and situation
to document and report .
• Recognize the professional methods of
documentation and reporting.

3
 Introduction
 Documentation is the primary communication tool to keep
all caregivers recognize and determine the needs, care &
progress of patient situation ,so that each caregiver knows
what everyone else is doing for a patient.

 Accurate documentation facilitates communication among

health care professionals who do not provide direct patient
care but are involved in various aspects of patient care.

4
 Definition

Documentation

Documentation is the written evidence of the

interactions between and among health
professionals, health care organizations, patients
and their families.

5
 Nursing Documentation and Nursing Process

Nursing documentation should be based on

the nursing process. Therefore, forms on
which nurses document should parallel or
relate to each step of the nursing process.
Needs could be tracked from assessment,
through identification of problems, care
plan, implementation and evaluation in
relation with the nursing process.
6
 Purposes of Documentation

 Communication.
 Legal protection.
 Education.
 Quality assurance.
 research
7
 Categories of Documentation Forms in
Clinical Record System

 Assessment and data base forms.

 Plan of care forms.

 Progress notes forms.

8
 Contents of a Clinical Record

 Patient identifying  Consent for treatment.

information.  Treatment goals and

 Past and current expected outcomes.

diagnoses ,health care  Medical, nursing and other

history. professional assessments,
orders, and plans of care.
 Reason for admission.
 Current medications.
 Known allergies.
9
 Contents of a Clinical Record

 Dietary patterns and  Release of information

restrictions. forms.
 Patient teaching plans and
 Consultation reports.
summaries.
 Transfer summary.
 Clinical progress notes.
 Discharge summary.
 Laboratory, radiology and
other diagnostic test
results.
10
 Principles of Recording

 Don’t pull a chart by room number only; check the name

on the chart too.
 Do make sure the patient’s name and ID number appear on
every page.
 Always use the hospital’s standard note form, and always
use the prescribed ink color.
 Do make entries in order of consecutive shifts and days,
Write the complete data at least once at the beginning of
your shift and at the top of every page of notes, Also
indicate the time of each entry.
 Don’t back date, or add to previously written note
11
Principles of Recording

 Do use concise phrases in narrative, begin each phrase

with a capital letter and start each new topic on a separate
line.
 Don’t skip lines between entries or leave a space between
phrases or in front of your signature.
 Do describe reported symptoms accurately. Use the
patient’s words when they are helpful.
 Don’t use medical terms unless you are sure of their
meanings.
 Do document nursing actions taken to correct a problem,
don’t just document the problem.
12
Principles of Recording

 Don’t use indefinite words and terms such as “apparently” and

“appears” to be.
 Do chart nursing procedures as soon as possible after doing
them.
 Don’t chart in advance or wait until the end of the day.
 If errors occurred, rewrite notes, mark the error on the original
sheet and leave it in the chart.
 Don’t repeat in your narrative what you have written on the
forms unless further explanation is needed. e.g. if you have
documented normal vital signs on the vital signs sheet, do not
repeat them in the nurses’ notes.

13
 Reporting

• introduction
• Verbal communication of data regarding the client ‘s health
status needs, treatment , outcomes and responses.

• Reports can be compiled daily, weekly, monthly, quarterly

and annually. Report summarizes the services of the nurse
and/ or the agency

14
Importance of reporting
• Good reports save duplication of effort and eliminate the
need for investigation to learn the facts in a situation.

• Patients receive better care when reports are thorough

and give all pertinent data.

• Complete reports give a sense of security which comes

from knowing all factors that related to patient status.
•

15
Criteria For a Good
Report
• Reports should be made promptly if they are to serve their
purpose well.

• A good report is clear, complete, concise.

• If it is written all pertinent, identifying data are include –

the date and time, the people concerned, the situation, the
signature of the person making the report

16
 Cont…
• . It is clearly stated and well organized for
easy understanding.

• No extraneous material is included.

• Good oral reports are clearly expressed and

presented in an interesting manner.
17
 Types of reports
• Verbal reports : reports are given when the
information is for immediate use, E.g. it is
made by the nurse who is assigned to patient
care, to another nurse.

18
 Cont…
• Written reports : when the information to be
used by several personnel, which is more or
less of permanent value, e.g. day and night
reports, census report, needed according to
situation, events and conditions.

19
 Reports Used In
Hospital Setting
• 1. Change- of- shift reports or 24 hours report:
• which include only essential information about
client (name, age sex, diagnosis and medical
history) but do not review all routine care
procedures or task.
• Identify clients’ nursing diagnosis
• Describe instructions given in teaching plan and
clients’ response.
• Share significant information about family
members, as it relates to clients’ problems. 20
 Cont…
• 2. Transfer reports
• A transfer reports involve communication of
information about clients from the nurse on
sending unit to the nurse on the receiving
unit.

21
 Cont…
• Nurse should include the following
information:
• Client’s name, age, primary doctor, and medical
diagnosis.
• Summary of medical progress up to the time of transfer.
Current health status- physical and psychosocial.
• Current nursing diagnosis or problems and care plan.
• Any critical assessment or interventions to be completed
shortly.
• Needs for any special equipments
22
 Cont…
• 3. Incident reports
• record details of an unusual event that occurs at the facility,
such as an injury to a patient ,medication error .
• The nurse who witnessed the incident should file the
report.
• The nurse describes in concise what happened specifically
• The nurse does not interpret or attempt to explain the cause
of the incident

23
 Cont…
• 4. Census report
• This is a report compiled daily for the number of
patients. Very often it is done at midnight and the
norms are collected by the night supervisor.
• The report will show the total number of patients,
the number of admissions, discharges, transfers,
births and deaths.

24
 How to write a better report
• Before anything can be written clearly, it must be
clear in one’s own mind.
• Reports, lacking facts, may be biased or worthless.
• Conciseness, accuracy and completeness are
essential to good reports.
• Use correct pronoun
• Don’t forget punctuation

25
 Cont..
• Use terminology in keeping with the
nature of reports:
• Short, simple, commonly used words for
nontechnical reports.
• Scientific terms when issuing reports to
professional personnel.
• If report is typed by someone else, check it before
signing it.

26
 Cont…
• Spell properly; avoid abbreviation except in
clinical charting.
• Be neat
• Write report in a conversational manner.
• Date reports

27
SUMMARY
28
 REFERENCES
• Planning and management in nursing Book ,
2nd edition , james harris,linda Roussel

• Slideshare.com

29