DOCUMENTINGand

REPORTING

Ma. Tosca Cybil A. Torres, RN, MAN

Objectives:• At the end of the discussion, the students will

be able to:1.Define documentation and reporting.2.State the importance of documenting and

reporting to the nursing profession.3.Write or formulate own nurse’s notes using

the traditional and SOAPIE format4.Use commonly used abbreviations correctly

PRETEST!IDENTIFY THE FF. IDENTIFY THE FF.

ABBREVIATIONS:ABBREVIATIONS:1.1.DATDAT2.2.o.u.o.u.3.3.b.i.db.i.d4.4.BPBP5.5.gtt.gtt.6.6.h.s.h.s.7.7.IMIM8.8.IVIV9.9.p.op.o10.10.KVOKVO

11.11.p.c.p.c.12.12.p.r.n.p.r.n.13.13.a.c.a.c.14.14.q.i.d.q.i.d.15.15.k.s.sk.s.s16.16.StatStat17.17.T.i.d.T.i.d.18.18.q. 15 mins.q. 15 mins.19.19.NGTNGT20.20.KUBKUB

• DOCUMENTATION serves as a permanent record of client information and care.

• REPORTING takes place when two or more people share information about client care, either face to face or by telephone

Purposes of Client’s Record Chart1.1. Communication. Communication. Provides efficient and Provides efficient and

effective method of sharing information.effective method of sharing information.2.2. Legal Documentation. Legal Documentation. It is admissible as It is admissible as

evidence in a court of law.evidence in a court of law.3.3. Research. Research. Provides valuable health-Provides valuable health-

related data for research.related data for research.4.4. Statistics. Statistics. Provides statistical information Provides statistical information

that can be utilized for planning people’s that can be utilized for planning people’s future needs.future needs.

5.5. Education. Education. Serves as an educational tool Serves as an educational tool for students in health discipline.for students in health discipline.

6.6. Audit & Quality Assurance. Audit & Quality Assurance. Monitors Monitors the quality of care received by the client the quality of care received by the client and the competence of health care givers.and the competence of health care givers.

7.7. Planning Client Care. Planning Client Care. Provides data Provides data which the entire health team uses to plan which the entire health team uses to plan care for the client.care for the client.

8.8. Reimbursement. Reimbursement. Provides the basis for Provides the basis for decisions regarding care to be provided decisions regarding care to be provided and subsequent reimbursement to the and subsequent reimbursement to the agency, to cover health-related expenses.agency, to cover health-related expenses.

Communication• is a process in which people affect one another

through exchange of information, ideas, and feelings.

MODES OF COMMUNICATION• Verbal communication. Uses spoken or written

words.• Nonverbal communication. Uses gestures, facial

expression, posture/gait, body movements, physical appearance (also body language), eye contact, tone of voice.

Characteristics of communication▫Simplicity. Includes use of commonly understood words,

brevity and completeness.▫Clarity. Involves saying exactly what is meant. The nurse also

needs to speak slowly and enunciate words well. Repeat the message as needed. Reduce distractions.

▫Timing and Relevance. Require choice of appropriate time and consideration of client’s interests and concerns. Ask one question at a time. Wait for an answer before making another comment.

▫Adaptability. Involves adjustment on client.▫Credibility. Means worthiness or belief. To become

credible:-adequate -provide accurate information-convey confidence and certainly in

what she says

-be a good model for what she teaches.

Communication is a basic component of human relationships and nurse-client relationships.

• Is a dynamic, continuous and multidimensional process for sharing information as determined by standards or policies.

•Non-verbal communication is a more acute expression of a person’s thoughts and feelings than verbal communication.

• When assessing non-verbal behaviors, consider cultural influences. Variety of feelings can be expressed by a single non-verbal expression. E.g. head nodding does not always mean agreement.

• Effective communication is reciprocal interaction (two-way process) based on trust and aimed at identifying client needs and developing mutual goals

• Trust is a foundation of a positive nurse-client relationship.

The characteristic of an effective nurse-

client relationship are as follows• An intellectual and emotional bond between the

nurse and the patient and is focused on the patient.

• Respects the client as an individual-his ability to participate in his care, ethnic and cultural factors, family relationship and values.

• Respects client’s confidentially.• Based on mutual trust and acceptance.

TYPES

OF RECORDING

Types of RecordA.SOURCE ORIENTED

MEDICAL RECORD > Each person or department makes notations in a

separate section/s of the client’s chart.> Most Traditional> Different disciplines chart on separate forms> Each reader must consult various parts of the

record to get a complete picture> Records become bulky

SOURCE ORIENTED MEDICAL RECORD

NARRATIVE CHARTING (TRADITIONAL CLIENT RECORD)

▫Most flexible of all methods and is usable in any clinical setting.• Five Basic components of a Traditional Client

Record admission sheet physician’s order sheet Medical history Nurse’s notes Special records and reports (referrals, X-ray, reports, laboratory findings, report

of surgery, anesthesia record, flow sheets, vital signs, I&O, Medications)

B. Problem-Oriented medical record (POMR or POR)

– The record integrates all data about the problem, gathered by the members of the health team.

FOUR BASIC COMPONENTS OF POMR/POR

1. Database. 2. Problem list.3. Initial list of orders or care plans.4. Progress notes:

◦ Nurse’s or narrative notes (SOAPIE format)Nurse’s or narrative notes (SOAPIE format)Subjective, Objective, Analysis, Planning, Intervention, Subjective, Objective, Analysis, Planning, Intervention,

EvaluationEvaluation◦ Flow sheets (data that are monitored)Flow sheets (data that are monitored)◦ Discharge notes or referral summariesDischarge notes or referral summaries

Methods (STYLES)

OF CHARTING

A.Nurse’s or narrative notes (SOAPIE format)

• S- SUBJECTIVE. WHAT PT TELLS YOU.• 0 – OBJECTIVE. WHAT YOU OBSERVE, SEE.• A – ASSESSMENT. WHAT YOU THINK IS GOING ON

BASED ON YOUR DATA.• P – PLAN. WHAT YOU ARE GOING TO DO.CAN ADD TO BETTER REFLECT NURSING PROCESS• I – INTERVENTION (SPECIFIC INTERVENTIONS

IMPLEMENTED)• E – EVALUATION. PT RESPONSE TO

INTERVENTIONS.• R – REVISION. CHANGES IN TREATMENT.

B. PIE CHARTING• Similar to SOAP charting• Both are problem-oriented• PIE comes from the Nursing Process, SOAP comes from a Medical

Model.• P-Problem• I-Intervention• E-EvaluationEx:• P#1 Risk for trauma related to dizziness.• IP#1 Instructed to call for assistance when getting OOB. Call light in reach.• EP#1 Consistently call for assistance before getting OOB. Continues to experience dizziness.

C. FOCUS CHARTING• USES NARRATIVE DOCUMENTATION (DAR)

• DATA – SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE FOCUS (CONCERN)

• ACTION – NURSING INTERVENTION

• RESPONSE – PT RESPONSE TO INTERVENTION

Ex:• D – COMPLAINING OF PAIN AT INCISION SITE , PS: 7/10• A – REPOSITIONED FOR COMFORT. DEMEROL 50MG IM GIVEN.• R – STATES A DECREASE IN PAIN, “FEELS MUCH BETTER.”

D. COMPUTERIZED CHARTING• PASSWORD. NEVER SHARE. CHANGE

FREQUENTLY.• LEGIBLE• CAN BE VOICE-ACTIVATED, TOUCH-ACTIVATED.• DATE AND TIME AUTOMATICALLY RECORDED.• ABBREVIATIONS AND TERMS ARE SELECTED BY A

MENU PROVIDED BY THE FACILITY.• TERMINALS ARE USUALLY EASILY ACCESSIBLE, IN

PT ROOMS, CONVENIENT HALLWAY LOCATIONS.• MAKE SURE TERMINAL CANNOT BE VIEWED BY

UNAUTHORIZED PERSONS.

KardexProvides a concise method of organizing and Provides a concise method of organizing and

recording data about a client, making recording data about a client, making information readily accessible to all members information readily accessible to all members of the health teamof the health team

It is a series of flip cards usually kept in It is a series of flip cards usually kept in portable fileportable file

It is a way to ensure continuity of care from It is a way to ensure continuity of care from one shift to another and from one day to the one shift to another and from one day to the nextnext

It is a tool for change – of – shift report. But It is a tool for change – of – shift report. But endorsement is not simply reciting content of endorsement is not simply reciting content of kardex. Health care needs of the client is still kardex. Health care needs of the client is still primary basis for endoresement.primary basis for endoresement.

• Usually include the ff. data:Usually include the ff. data:– Personal dataPersonal data– Basic needsBasic needs– AllergiesAllergies– Diagnostic testsDiagnostic tests– Daily nursing proceduresDaily nursing procedures– Medications and intravenous (IV) therapy, Medications and intravenous (IV) therapy,

blood transfusionsblood transfusions– Treatments like oxygen therapy, steam Treatments like oxygen therapy, steam

inhalation, suctioning, change of dressings, inhalation, suctioning, change of dressings, mechanical ventilation.mechanical ventilation.

• Entries usually written in pencil. This Entries usually written in pencil. This implies the kardex is for planning ang implies the kardex is for planning ang communication purpose only.communication purpose only.

GENERAL DOCUMENTATION GUIDELINES

* Ensure that you have the correct client record or chart.* Document as soon as the client encounter is concluded to

ensure accurate recall of data.* Date and time of each entry.* Sign each entry with your full legal name and with your

professional credentials.* Do not leave space in between entries.* If an error is made while documenting, use a single line to

cross out the error, then date, time and sign the correction

* Never change another person’s entry even if it is incorrect

* Use quotation marks to indicate direct client responses.* Document in chronological order* Use permanent ink* Document all telephone calls that you received that are

related to client’s case.

Characteristic of Good Recording:• BREVITYBREVITY– Entries are conciseEntries are concise– Complete sentences are not requiredComplete sentences are not required– Start each entry with a capital letter Start each entry with a capital letter

and end the entry with a period even if and end the entry with a period even if the entry is a single word or phrase.the entry is a single word or phrase.

• USE INK/PERMANENCEUSE INK/PERMANENCE– Avoid pencil for permanence of data, Avoid pencil for permanence of data,

because the client’s chart can be used because the client’s chart can be used as an evidence in a legal court.as an evidence in a legal court.

•ACCURACYACCURACY– Chart objective facts, not your Chart objective facts, not your

interpretations or opinionsinterpretations or opinions– Eg.Eg.

Ate 50% of the food served.Ate 50% of the food served.Ate with poor appetite.Ate with poor appetite.

Refused medications.Refused medications.Uncooperative.Uncooperative.

Seen crying.Seen crying.Depressed.Depressed.

– Place complaint of the client in Place complaint of the client in quotation marks to indicate that quotation marks to indicate that it is his statement.it is his statement.

““chest pain radiating down the left chest pain radiating down the left arm”arm”

““nahihirapan akong huminga kapag nahihirapan akong huminga kapag nakahiga”nakahiga”

– Objective data are also to be Objective data are also to be charted.charted.

E.g. skin cold and clammy. Diaphoretic. E.g. skin cold and clammy. Diaphoretic. Prefers to sit up. Vital signs taken as Prefers to sit up. Vital signs taken as follows: temp-37.6C, PR-110/min., RR-follows: temp-37.6C, PR-110/min., RR-26/min. BP-140/90 mmHg.26/min. BP-140/90 mmHg.

– Describe behaviors rather than feelings to Describe behaviors rather than feelings to allow other health team members to allow other health team members to determine the actual problems of the client.determine the actual problems of the client.

– Refusal of medications and treatments Refusal of medications and treatments must be documented.must be documented.

• APPROPRIATENESSAPPROPRIATENESS– Only information that pertains to the Only information that pertains to the

client’s health problems and care are client’s health problems and care are recorded.recorded.

– Any other personal information that is Any other personal information that is conveyed to the nurse is appropriate for the conveyed to the nurse is appropriate for the record.record.

•Completeness and chronology/organization/sequence/timing.– Notes should appear on each succeeding line– Continuous charting is done for each entry unless a time change

occurs. No need for a new line for each new idea or entry.– Date is entered in the date column on the first line of every page

of nurse’s notes and whenever the date changes.– Time is entered in the time column whenever a new time entry

occurs.– Avoid time changes in the text of nurse’s notes.– Avoid double chart. If something appears on a particular sheet,

it does not need to appear on the nurse’s notes, unless there is an alternation from the normal, e.g. body temperature, blood pressure.

– Avoid squeezing information to a space because you forgot to chart it earlier. Add the information on the first available line. Write the time the event occurred, not the time you entered the information.

The following information should be charted:o Physician’s visits.o Times the patient leaves and returns to the unit, mode of transportation and

destination.o Medications should be charted immediately after administration.o Treatments should be charted immediately after being done.

 • Use of standard terminology

Use only those abbreviations and symbols approved by the institution; spell correctly; use proper grammar.

• Signed. Affix signature, place at the end of charting, at the right hand margin of the

nurse’s notes. Sign each entry with your full name and status, e.g. SN for Student Nurse,

RN for registered nurse. Script, not printing is used for the signature.

•In case of error.* Correct errors by drawing a single horizontal line * through the error* Write the word error above the line, then sign * your signature* No ink eradication, erasures or use of occlusive materials.

•Confidentiality.– Only the health personnel who participate in the care of the client

are allowed to read the chart.

• Legal awareness– Chart only what you personally have done, observe, heard,

smelled, or felt.– Do not discard any of the client record.

•Legible– Writing must be clear and easily read by others– If writing is not legible, then print.

• A horizontal line drawn to fill up a partial line. This is to prevent other persons from adding information in the nurse’s notes.

E.g.E.g.Needs attended. Referred accordingly.-------Ma. Tosca Needs attended. Referred accordingly.-------Ma. Tosca

Cybil Torres, RN, MANCybil Torres, RN, MAN

REPORTIN

G

REPO

RTIN

G– takes place when two or more people share information

about client care , either face to face or by telephone.

Types of reporting• Walking rounds• change – of – shift reports or

endorsement– for continuity of care– it is based on health care needs of the client– it is not mere reciting the content of the kardex

• Telephone reports– provide clear accurate and concise information– the nurse documents telephone report by including the following

information:• when the call was made• who made the call/report• who was called• to whom information was given• what information was given • what information was received

• Telephone orders – Only RN’s may receive telephone orders– The order need to be verified by reporting it clearly and

precisely.– The order should be countersigned by the physician

who made the order within the prescribed period of time (within 24 hours)

• Transfer reports– this is done when transferring a client from unit to

another.

• Incident Reports or occurrence reports– Used to document any unusual occurrence or

accident in the delivery of client care

Group ActivitySituation:• Antonio, a 55 y/o farmer, was found by his son lying on the floor unconscious. He was brought to the ER and was diagnosed with CVA, probably bleed. He is then admitted to the medical ICU for continuity of critical care. He is drowsy, restless at times, severely dyspneic, and with excessive secretions. Crackles are heard upon auscultation at both lower lung fields. V/S: BP 190/110mmHg, T° 39°C, RR 38cpm, PR 112bpm