Documentation system Application for Models for Application for Models for

Organization and Guidelines for Organization and Guidelines for ContentsContents

1- Source oriented record: the information about a patient's care and illness is organized according to the "source" of the information within the record, f it is recorded by the physician, the nurse, or data collected from an x ray or laboratory test are filed under their specific sectionalized areas in the chart usually in chronological order. Many facilities use this format since it is easy to locate documents.

For example, if a physician needs to reference a recent lab report, it can easily be found in the laboratory section of the record. However, if a physician wanted to reference all information about a particular diagnosis being treated or treatment given on a particular day, many sections of the record would have to be referenced making it difficult to amass all the information for that specific diagnosis difficult.

Each person or department make notations in a separate section or section of the client chart.

Narrative charting is a traditional part of the source oriented record .

Advantages Disadvantages

Convenient and easy to trace . The information about the a particular client problem is

scattered throughout the client chart .

Cont ’

2- problem oriented medical record :The data arranged according to the problem the

client has rather than the source of the information. we will define problem as anything that interferes with the health, well being and quality of life of an individual, that may be medical, surgical, obstetric, social or psychiatric,

The health team contribute to the problem list , plan of care and progress note .

Cont’

Advantages Disadvantages

a) Encourages collaboration a) Caregivers differ in their ability to use the required charting format .

b) The problem list in front of the chart alert the caregivers to the client needs and makes it easer to track the status of each problem .

b) It tack constant vigilance to maintain an up-to- date problem list.

c) It is somewhat inefficient .

Cont’

The problem oriented medical record has 4 basic component : (POR) has four parts:

1- Database . Is an overview of patient information

2- problem list . The problem list is the first document encountered in the patient's chart. It serves as a guide to the current and important health problems of the patient.

3- plan of care . which specifies what is to be done with regard to each problem

4- progress note . which document the observations, assessments, nursing care plans, physician's orders, etc., of allhealth care personnel directly involved in the care of the patient. .

Cont’

3- The Integrated Health Record FormatThe Integrated Health Record Format : Integrated health record format organizes all the paper

forms in strict chronological order and mixes the forms created by different departments.

TYPES OF RECORDS 1 .Patients clinical record 2 .Individual staff records

3 .Ward records Administrative records with educational

value. 4   .

PATIENTS CLINICAL RECORDS  It is the knowledge of events in the patient illness, progress in his or her recovery and the type of care given by the hospital personnel .

INDIVIDUAL STAFF RECORDS. • A separate set of record is needed for staff, giving details of their sickness and absences, their carrier and development activities and a personnel note  

.WARD RECORDS. • Reducting or increase in beds. • Change in medical staff and non nursing personnel

for the ward .•ADMINISTRATIVE RECORDS WITH EDUCATIONAL

VALUE. • • • • • Treatments. Equipments losses and replacements. Personnel performance. Other

administrative records .  

Reporting

DEFINITION Reports are oral or written exchanges of information shared between care givers of workers in a number of ways. A report summarises the service of the personnel and of the agency

CRITERIA FOR A GOOD REPORT • made promptly. • clear, concise, and complete. • If it is written all pertinent, identifying data are included-the date and time, the people concerned, the situation, the signature of the person making the report. • It is clearly stated and well organized • Important points are emphasized. • In case of oral reports they are clearly expressed and presented in an interesting manner. 

The purpose of reporting is: to communicate specific information to a

person or group of people . (an essential tool to communication )

• To show the kind and amount of services rendered over a specific period.

• To illustrate progress in teaching goals. • As an aid in studying health condition. • As an aid in planning. • To interpret the services to the public and to the

other interested agencies. 

REPORTS IN NURSING EDUCATION •Factual data related to the students, staff,

clinical facilities, physical facilities, administration and the curriculum

•Development made in the school programme since the last report.

•Proposal and plans for future development . •Problems encountered

•Recommendations  

TYPES OF REPORTS 1 .24 hours reports

2 .Census report 3 .Anecdotal report

4 .Birth and death report 5 .Incidental report

CLASIFICATION OF REPORTS BASED ON TYPES

•Oral reports •Written reports

REPORTS USED IN HOSPITAL SETTING: •• •

•CHANGE – OF – SHIFT REPORTS TRANSFER REPORTS

INCIDENT REPORTS LEGAL REPORTS  

Types of report :1- Change – of- shift report : is report given to all the nurses next shift .It is purpose is to provide continuity of care for client.

Cont’

2- Telephone Report :The nurse receiving a telephone report should

document Ex:6/6/03 10:35 AM Omar Ahmad , laboratory

technician , reported by telephone that Mrs. Sara Mohammed hematocrit was 39/100ml ____ B.Irland RN.

Cont ’

When giving telephone report to a physician telephone report include

Ex: Dorothy Mendes admitted 12 noon; c/o burning

upper right quadrant abdominal pain, BP 120/80 , p 100, R 20 , on admission. Demerol 100 mg IM on admission , At 3:15 pm BP 100/40,P 120 , R 30. Pain unchanged. Color pale and diaphoretic . Reported by telephone to Dr. Burns at 2:10 pm ___ TS Jones RN.

Cont ’

3- Telephone Order :While the physician gives the order write it down

and repeated back to the physician .Ask the physician about any order that ambiguous,

unusual , or contraindicated by the client’s condition.

Transcript the order to the physician order sheet.The order must be countersigned by the physician within a time period described by agency policy .

Cont’

3- Care plan conference :Is a meeting of a group of nurses to discuss possible

solution to certain problem of the client . It is allow the nurses an opportunity to offer an opinion about possible solutions to the problem.

4- Nursing Round : procedure in which tow or more nurses visit

selected client at each client bed side to :a) Obtain information that will help plan nursing care.b) provide the client the opportunity to discuss their

care .C) Evaluate the nursing care the client has received .

ADVANTAGES AND DISADVANTAGES OF REPORTS ADVANTAGES• • • • •

Monitoring operations Controlling

Guide decision Employee motivation

Performance evaluation DISADVANTAGES • It is time consuming. • Expensive •

Reports can be biased • Sometimes implementations of the recommendations of a report become unrealistic. • Technical reports are not easily understandable

NURSES RESPONSIBILITY FOR RECORD KEEPING AND REPORTING • • • • • • Records and reports must be functional accurate, complete, current organized and confidential FACTS ACCURACY COMPLETENESS CURRENTNESS ORGANIZATION CONFIDENTIALITY

39 .

COMMON PROBLEMS THAT OCCUR DURING REPORT WRITING.

CONTENT AND ORGANIZATION • Problem - No section headings • Problem - missing items related to the format • Problem - lack of numbering

40 .Common problems that occur during report writing.(Contnd..)

GRAMMAR, VOCABULARY, SENTENCE AND TONE. OTHER PROBLEMS • Incomplete sentences • Confusing and unclear sentences. • Miscommunication • Too general • Confidentiality. • Missing information and facts. • Wordiness .

Basic essential reports

Documenting Nursing activities

1- Admission Nursing Assessment :

Cont’

2- Nursing care plans :

3- Kardexes:

4 -Flow sheet:

5 -Progress note:

Provide information about the progress a client is making toward achieving desired outcomes .

6-Nursing Discharge / referral Summaries

Completed when the client being discharged or transferred to another institution or to home where a visit by community health nurse .

If the client transferred within a facility or from long term facility to a hospital, a report needs to accompany the client to ensure continuity of care in the new area .

It is include some or all of the following :1- Description of the client status.2- Resolved health problem .3- unresolved health problem and continued care needs

Cont ’

4- Treatment that are to be continued .5- Current medication .6- restriction that are relates to activities, diet,

bath.7- functional / self care abilities.8- comfortable level .9- Support network .10- client education .11- Discharge distention.12- Referral services.

Thank you for your listening