Topic 4:

Documentation and
Reporting

Hussein E. Catanyag, MSN, RN

Lecturer, St. Paul University Quezon City
 Documentation and Reporting

Effective communication among health

professionals is vital to the quality of client care.
Generally, health personnel communicate through
discussion, reports, and records.
The process of making an entry on a client record
is called recording, charting, or documenting
Each health care organization has policies about
recording and reporting client data,
Each nurse is accountable for practicing
according to these standards
 Documentation and Reporting

ü A discussion is an informal oral consideration

of a subject by two or more health care
personnel to identify a problem or resolve a
problem.
ü A report is oral, written, or computer-based
communication intended to convey information
to others.
ü A record is a formal, legal document that
provides evidence of a client’s care and can
be written or computer based
Ethical and Legal Considerations

ü The client’s record is protected legally as a

private record of the client’s care.
ü Access to the record is restricted to health
professionals
ü For purposes of education and research, most
agencies allow student access to client
records
Purpose of Client Records

Communication - Different health professionals who

interact with a client communicate with each other.

Planning client care - Uses data from the client’s record

to plan care for that client.

Auditing health agencies - An audit is a review of client

records for quality assurance purposes

Legal documentation - The client’s record is a legal

document and is usually admissible in court as evidence.
Purpose of Client Records

Research - The information in a record can be a valuable source of

data for research.

Education - Students in health often use client records as

educational tools, these records can provide a comprehensive view
of the client, the illness, treatment, and factors that affect the illness.

Reimbursement - Documentation also helps a facility receive

reimbursement from the federal government.

Health care analysis - Information from records may assist health

care planners to identify agency needs, such as overutilized and
underutilized hospital services.
 DOCUMENTATION SYSTEMS

Documentation systems are:

1. the source-oriented record;

2. the problem-oriented medical record
3. the problems, interventions, evaluation (PIE) model;
4. focus charting;
5. charting by exception (CBE)
6. computerized documentation
7. case management.
 1. Source-Oriented Records

ü Traditional client record

ü Each discipline makes notations in a separate
section
ü Information about a particular problem
ü Narrative charting used
 1. Source-Oriented Records

• Source-oriented records are convenient

because care providers from each discipline
can easily locate the forms on which to record
data.
• The disadvantage is that this type lead to:
• decreased communication
• an incomplete picture of the client’s care
• lack of coordination of care
2. Problem-Oriented Medical Records (POMR)

• The data are arranged according to the

problems the client has rather than the source
of the information.
• Four basic components
• Database (all information known about the
client)
• Problem list
• Plan of care
• Progress
• Uses SOAP, SOAPIE, SOAPIER documentation
2. Problem-Oriented Medical Records (POMR)

• Advantages
• it encourages collaboration
• alerts caregivers to the client’s needs

• Disadvantages
• caregivers differ in their ability to use the
required charting format
• it is inefficient because assessments and
interventions that apply to more than one
problem must be repeated
 3. PIE Documentation

P I E
PROBLEM INTERVENTIONS EVALUATION
 3. PIE Documentation

• Advantages:
• Eliminates the traditional care plan and
incorporates an ongoing care plan
• The nurse does not have to create and
update a separate plan.

• Disadvantage:
• The nurse must review all of the nursing
notes before giving care to determine which
problems are current and which interventions
were effective.
 4. Focus Charting

Focus on client concerns and strengths

Data - assessment phase

Progress notes organized Action - planning and implementing phase

into DART format Response - evaluation phase

Teaching

Holistic perspective of client needs

Nursing process framework

4. Focus Charting
4. Focus Charting
 5. Charting by Exception (CBE)
• Is a documentation system in which only
abnormal or significant findings or
exceptions to norms are recorded.
• The advantages to this system are that it
eliminates lengthy, repetitive notes.
• CBE incorporates three key elements
• Flow sheets
• Standards of nursing care
• Bedside access to chart forms
 6. Case Management Model
• Quality, cost-effective care delivered within
established length of stay using critical
pathways
• Incorporates graphics and flow sheets
• Promotes collaboration and teamwork among
caregivers, helps to decrease length of stay,
and makes efficient use of time.
 7. Computerized Documentation
• Developed to manage volume of information
• Use of computers to store client’s database,
new data.
• Information easily retrieved
• Possible to transmit information from one care
setting to another
Security for Computerized Records
ü Passwords
ü Never leave computer terminal unattended
after logging on
ü Do not leave client information displayed
ü Know policy and procedure for correcting an
entry error
ü Follow agency procedures for documenting
sensitive material
 Documenting Nursing Activities

ü Admission Nursing Assessment

ü Nursing Care Plans
ü Kardexes
ü Flow Sheets
ü Progress Notes
ü Nursing Discharge/Referral Summaries
Admission Nursing Assessment

• A comprehensive
admission
assessment
• Also referred to as
an initial database,
nursing history, or
nursing
assessment, is
completed when the
client is admitted to
the nursing unit.
 Nursing Care Plans
• Traditional Care Plan
• written for each client
• have three columns: one for nursing diagnoses, a
second for expected outcomes, and a third for
nursing interventions

• Standardized Care Plan

• based on an institution’s standards of practice
• individualized by the nurse in order to adequately
address individual client needs.
 Kardexes
• The Kardex is a widely used, concise method
of organizing and recording data about a client
• Making information quickly accessible to all
health professionals.
• The system consists of a series of cards kept in
a portable index file or on computer-generated
forms.
• May or may not become a part of the client’s
permanent record.
• A temporary worksheet written in pencil for
ease in recording frequent changes in details of
a client’s care
 Kardexes

Pertinent information
about the client, Allergies List of medications,

List of daily
List of intravenous treatments and List of diagnostic
fluids procedures ordered,
procedures

A problem list, stated

client’s physical goals, and a list of
needs nursing approaches
to meet the goals.
 Flow Sheets
• A flow sheet enables nurses to record nursing
data quickly and concisely and provides an
easy-to-read record of the client’s condition
over time.

Examples :
ü Graphic record
ü Intake and output
ü Medication administration record
ü Skin assessment record
 Progress Notes

Provide information about progress client

is making toward achieving desired
outcomes

Include information about client problems

and nursing interventions
Nursing Discharge/Referral Summaries
• Completed when client discharged or transferred to
another institution.
ü Description of client’s physical, mental, and emotional status at
discharge or transfer
ü Resolved health problems
ü Unresolved health problems
ü Treatments that are to be continued (e.g., wound care, oxygen
therapy)
ü Current medications
ü Restrictions that relate to activity, diet, bathing
ü Client education provided in relation to disease process,
activities and exercise, special diet, medications, specialized
care or treatments, follow-up appointments, and so on
ü Discharge destination (e.g., home, nursing home) and mode of
discharge (e.g., walking, wheelchair, ambulance)
ü Referral services (e.g., social worker, home health nurse).
Factors to Consider in Documenting Care

ü Date and time

ü Timing
ü Legibility
ü Permanence
ü Accepted terminology and correct spelling
ü Signature
ü Accuracy
ü Sequence
ü Appropriateness
ü Completeness
ü Conciseness (no extra details)
ü Legal care
Reporting
Guidelines for Reporting Client Data
• Types of reporting:
• Change-of-shift report
• Telephone reports
• Care plan conference
• Nursing rounds
 Change-of-Shift Report
• Standardized approach to “handoff”
communication
• Given to all nurses on the next shift
• Change-of-shift reports may be written or given
orally
• Many hospitals use the SBAR tool along with a
verbal report for handoffs for change-of-shift
reports
Change-of-Shift Report
Change-of-Shift Report
 Telephone Report
• The nurse receiving a telephone report should
document the date and time, the name of the
person giving the information, and the subject
of the information received, and sign the
notation.
• The person receiving the information should
repeat it back to the sender to ensure
accuracy.
 Telephone Orders
• Most agencies have specific policies about
telephone orders
• Only RNs to take telephone orders.
• While the physician gives the order, write the
complete order down on the physician’s order
form and read it back to the physician to
ensure accuracy.
• Once the order is written on the physician’s
order form, the order must be countersigned
by the physician within a time period described
by agency policy. Many hospitals require that
this be done within 24 hours.
 Care Plan Conference
• A meeting of a group of nurses to discuss
possible solutions to certain problems of a
client
• Allows each nurse the opportunity to offer an
opinion about possible solutions
• Other health care providers invited to offer
expertise
 Nursing Rounds
• Two or more nurses visit selected clients at bedside
• Obtain information that will help plan nursing care and evaluate
care given
• Provides clients opportunity to discuss their care
• Need to use terms client can understand
 Learning Task
1. Medical abbreviations worksheet in Open
LMS (can also be downloaded in Teams
2. 10-items Quiz in Open LMS (Wednesday
8am – 5pm)