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
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