Documenting And Reporting

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  • DOCUMENTING and REPORTING Ma. Tosca Cybil A. Torres, RN, MAN
  • Objectives :
    • At the end of the discussion, the students will be able to:
    • Define documentation and reporting.
    • State the importance of documenting and reporting to the nursing profession.
    • Write or formulate own nurses notes using the traditional and SOAPIE format
    • Use commonly used abbreviations correctly
  • PRETEST!
    • IDENTIFY THE FF. ABBREVIATIONS:
    • DAT
    • o.u.
    • b.i.d
    • BP
    • gtt.
    • h.s.
    • IM
    • IV
    • p.o
    • KVO
    • p.c.
    • p.r.n.
    • a.c.
    • q.i.d.
    • k.s.s
    • Stat
    • T.i.d.
    • q. 15 mins.
    • NGT
    • KUB
    • 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 Clients Record Chart
    • Communication. Provides efficient and effective method of sharing information.
    • Legal Documentation. It is admissible as evidence in a court of law.
    • Research. Provides valuable health-related data for research.
    • Statistics. Provides statistical information that can be utilized for planning peoples future needs.
    • Education. Serves as an educational tool for students in health discipline.
    • Audit & Quality Assurance. Monitors the quality of care received by the client and the competence of health care givers.
    • Planning Client Care. Provides data which the entire health team uses to plan care for the client.
    • Reimbursement. Provides the basis for decisions regarding care to be provided and subsequent reimbursement to the 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 clients 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 persons 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 clients confidentially.
    • Based on mutual trust and acceptance.
  • TYPES OF RECORDING
  • Types of Record
    • SOURCE ORIENTED MEDICAL RECORD
      • Each person or department makes notations in a separate section/s of the clients 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
          • physicians order sheet
          • Medical history
          • Nurses 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
    • Database.
    • Problem list.
    • Initial list of orders or care plans.
    • Progress notes:
      • Nurses or narrative notes (SOAPIE format)
      • Subjective, Objective, Analysis, Planning, Intervention, Evaluation
      • Flow sheets (data that are monitored)
      • Discharge notes or referral summaries
  • Methods (STYLES) OF CHARTING
    • Nurses 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 -Evaluation
    • Ex:
    • 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 RE