✓ Database - consists of all information known

 DOCUMENTING/RECORDING & about the client when the client first enters the health

✓ Problem List - problems are listed in the order in

REPORTING Care agency
➤"Effective communication among health
professionals is vital to the quality of client care." which they are identified, and the list is continually
updated as new problems are identified and others are

✓ Plan of Care - the initial list of orders or plan of

 DISCUSSION resolved.

care is made with reference to the active problems. ✓

➤is an informal oral consideration of a subject by
two or more health care personnel to identify a
problem or establish strategies to resolve a problem. Progress Notes - is a chart entry made by all health
professionals involved in client's care.
 REPORT It has different format:
➤Is oral, written, or computer-based communication ₒ SOAP- subjective data, objective data, analysis
intended to convey information to others. and planning.
ₒ SOAPIE or SOAPIER - same above with
 RECORD Interventions, evaluation and revision.
➤is a written or computer based. ₒ PIE - Problems, Interventions, and Evaluation

✓Caregivers differ in their ability to use the required

 RECORDING Its disadvantages are:
➤ also called charting or documenting. is the process
of making an entry on a client record . charting format. It takes constant vigilance to

✓ It is somewhat inefficient because assessments and

maintain an up-to-date problem list
 CLINICAL RECORD
➤ also called chart or client record. It is a formal, interventions that apply to more than one problem
legal document that provides evidence of a client's must be repeated.
care.
 FOCUS CHARTING
 ETHICAL AND LEGAL PRINCIPLES ➤is intended to make the client and client concerns
➤"The nurse has a duty to maintain confidentiality of and strengths the focus of care.
all patient information" ➤Three columns for recording are usually used: date
➤"The client's record is also protected legally as a and time, focus, and progress notes.
private record of the client's care." ➤Utilizes DAR: data, action and response.
➤"Access to the record is restricted to health
professionals involved in giving care to the client"  COMPUTERIZED DOCUMENTATION
➤"The institution or agency is the rightful owner of ➤are being developed as a way to manage the huge
the client's record" volume of information required in contemporary
health care.
 PURPOSES OF CLIENT RECORDS ➤ Nurses use computers to store the client's database,
➤Communication,Planning client care, Auditing add new data, create and revise care plans and
Health Agencies, Research,,Education, document client progress.
Reimbursement, Legal Documentation, Health Care
Analysis.  DOCUMENTING NURSING ACTIVITIES
1. Admission Nursing Assessment
 DOCUMENTATION SYSTEMS ➤also referred to as an initial database, nursing
ₒ SOURCE-ORIENTED RECORD history, or nursing assessment, is completed when
➤the traditional client record the client is admitted to the nursing unit.
➤each person or department makes notations in a 3.Kardexes
separate section/s of the client's record ➤is a widely used, concise method of organizing and
➤Examples: the admission dept. - Admission sheet. recording data about a client, making information
the physician - Doctor's order sheet. A physician's quickly accessible to all health professionals.
history sheet. Progress notes. ➤the system consists of a series of cards kept in a
portable index file or on a computer-generated
ₒ Narrative Charting - forms.
➤is the traditiomal part of the source-oriented record.
➤It consists of written notes that include routine care,  GENERAL GUIDELINES FOR RECORDING
normal findings, and client problems. ➤Date and Time, Timing, Legibility, Permanence,
Accepted Terminology, Correct Spelling, Signature,
ₒ PROBLEM-ORIENTED/MEDICAL RECORD Accuracy, Sequence, Appropriateness, Completeness,
(POMR) - Conciseness, Legal prudence.
➤Established by Lawrence Weed in the 1960s
 REPORTING (Purpose:)
ₒ MEDICAL RECORD ➤ to communicate specific information to a person or
➤the data arranged according to the problems the group of people.
client has rather than the source of the information

It has the four basic components: