RECORDING / REPORTING

Recording
Records are written accounts of patients observation and therapy. are written, formal, legal documentation of the clients progress. Patients Record/chart/hospital chart - Is a legal document which provides evidence of the care given to a patient in a particular agency. - Is a communication linkage or system by which members of the health team exchange views and information about the patient and his therapy.

Purposes of Client Record

Planning client care Communication Legal documentation Research Education Nursing audit Statistics Accrediting and licensing Reimbursement

Contents of the Patients Chart

1. 2. 3. 4. 5. 6. 7. Face sheet Admission Form Medical History Nursing History Graphic Sheet Activity Flow Chart Medication Sheet / Record 8. Doctors order sheet 9. Nurses notes 10. Progress notes 11. Laboratory sheet 12. Problem list 13. Health team notes 14. Discharge plan

Nurses Notes / charting

is the method used to document, using the nursing process, which includes the observations that the nurse made about the patients condition, the statement of the problem, the care, and the treatment that was delivered and the patients response.

Guidelines for determining when charting is required:

1. 2. Chart anytime the patients condition warrants it. Admission date must be recorded as soon as possible after the patient is admitted. Record medication administration as soon as possible. If the patient leaves the nursing unit, make a notation in the chart before the patient leaves and upon the patients return. Chart relevant observation

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Record any unusual or untoward incident, the time, the result of nursing actions and the patients response promptly and completely. 7. Document anytime when the nurse gives care, treatments, or makes an assessment of the patient. 8. Visits by members of the health team. 9. The therapeutic measures ordered by the physician. 10. Specific measures the physician carries out on her own. 11. Evaluation of the effectiveness of nursing interventions measures both dependent and independent.

Guidelines for Recording

Writing must be legible On every notation, document the date and time of the recording and of the assessment or intervention. No recording should be done before providing nursing care. Clients record is restricted to members of the health team included on the care of the patient. All entries on the clients record are made in dark colored ink. Sign each recording and include first and last name and the title of the person making the notation. Accurate notations consist of facts or exact observations rather than opinions or interpretations of an observation.

 When describing something, nurses should avoid general words such as large, good and normal. Correct spelling is essential for accuracy in recording Errors should not be erased or blotted out. Document events chronologically, what happens first, next and last. Only information that pertains to the clients health problems and care is recorded. Use only commonly accepted abbreviations, symbols, and terms that are specified by the agency. Recordings need to be brief as well as complete. Do not leave space between entry. Legal awareness

Two General Forms of Records

1. Source Oriented / Traditional Record. 2. Problem Oriented / Medical Record

1. Source Oriented Record

- Is the information about the patients care that is narrative form and is usually charted in chronological order regardless of the topic under consideration. - Information is organized according to the source of that information.

2. Problem Oriented Record (POR)

- Is organized according to the identified problem of the patient. - All members of the health care team write proper notes about the same problem on the same problem on the same form in the chart.

Components of POR
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Baseline Data consist of all the information about a patient obtained during admission. Problem List is a series in chronological order of identified patient problem or diagnosis - result of manipulation and interpretation of new information collected in the database. Initial plan of Care completed as soon as possible after admission and is the beginning looking plan of the team. Progress notes

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Kinds of Progress Notes

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Narrative Charting records patient progress in a day to day basis. SOAP / SOAPIER format PIE charting Flow Sheets is designed to facilitate the recording of recurring treatment or observation in a graphic form. Discharge Notes a description of problem identified, and the degree to which each problem has been resolved, accomplished during the patients discharge Discharging a client Against Medical Authority

Other Written Documentation

Kardex it is a summary of the patients problem and therapy and is readily accessible to all members of health team as well as being used during changes of shift.