UNIT 4: DOCUMENTATION

AND REPORTING

GUIDELINES/PROTOCOLS/TOOLS
IN REPORTING RELATED TO
CLIENT CARE
Pg.91
Learning Outcomes:

At the end of this chapter, the students will be

able to:
Define documenting and reporting
Discuss different documentation system
Perform correct documentation and report
Explain ISBAR, Incident Report, Referral System
and Healthcare Electronic Databases
DOCUMENTING
charting or recording
accurate, comprehensive and
flexible
Confidentiality observed at all
times.
DOCUMENTATION
Written or printed record served
as proof
Effective documentation ensures
continuity of care saves time and
minimizes the risk of error
Nurse’s has direct
responsibility in
maintaining
confidentiality of client’s
information.
 Purposes of Client Records

A. Communication
vehicle by which different health
professionals who interact with a
client communicate with each other.
prevents fragmentation, repetition and
delays in client care.
 Purposes of Client Records
B. Planning client care
Data from the client’s record can be used
as a basis in planning care for the patient.
C. Auditing health agencies
This allows accrediting agencies to
determine if a particular health agency is
meeting its stated standards.
 Purposes of Client Records
D. Research
Information from the client’s record
can be used as a source of data for
research.
E. Education
This can be used as educational tool
by students.
 Purposes of Client Records
F. Reimbursement
obtain payment from medicare or
insurance companies.
G. Legal documentation
-admissible in court as evidence
Purposes of Client Records

H. Health care analysis

 assist in identifying agency
needs, such as underutilized
or over utilized hospital
services
 Documenting Nursing Activities

A. Admission Nursing Assessment

-initial database, nursing history or
nursing assessment.
-Can be organized according to health
patterns, body systems, functional
abilities, health problems and risks,
nursing model or type of health care
setting.
 Documenting Nursing Activities
B. Nursing Care Plans
2 types:
Traditional care plans – written for each client;
most forms have three columns containing the
nursing diagnoses, expected outcomes and
nursing interventions (Berman, et.al, 2015)
Standardized care plans – developed to save
documentation time; may be based on an
institution’s standards of practice
 Documenting Nursing Activities

C. Kardex
A widely used, concise method of
organizing and recording data
about a client
Consists of a series of cards kept
in a portable index file or on
computer-generated forms
Documenting Nursing Activities

D. Flow Sheets
Graphic record, intake and
output record, medication
administration record, skin
assessment record
Documenting Nursing Activities

E. Progress Notes/nurse’s notes

Made by nurses to provide
information about the progress
a client is making towards
achieving desired outcomes
 Documenting Nursing Activities

F. Nursing Discharge
refers to a record of the client’s
condition after admission and
include instructions for the client
upon discharge.
Documenting Nursing Activities

G. Referral Summaries
Given to a patient for transfer to
another institution; this includes
the patient’s history, diagnosis,
laboratory test result,
medications, etc. of the patient
 General Guidelines for Recording
Date and Time
-Record time in a conventional manner or
according to military time.
Timing
-Follow agency’s protocol about the frequency of
documentation.
-Adjust frequency as the client’s condition
indicates.
General Guidelines for Recording

Legibility
easy to read to prevent misinterpretation.
Permanence
Use dark ink so that the record is
permanent.
Follow agency’s policy about the type of
pen and ink used for recording.
General Guidelines for Recording
Accepted terminology
Use only commonly accepted abbreviations,
symbols and terms specified by the agency.
If in doubt, write the term in full.
Correct spelling
accuracy in recording.
If unsure of the spelling, look it up in a
dictionary or other resource books.
 General Guidelines for Recording

Signature
Include name and title.
Sign only entries you made.
Some agencies may have signature sheets,
after signing this signature sheet, nurses can
use their initials.
In computerized charting, each nurse has
own code.
General Guidelines for Recording
Accuracy
Client’s name and identifying information
should be written on each page of the
record.
Before making an entry, check that it is the
correct chart
Identify charts by name and not by room
number.
General Guidelines for Recording

Special care is needed when

caring for clients with the same
last name.
Quote exact words of patient.
Avoid general words such as
large, good, well or normal
 General Guidelines for Recording
When a recording mistake is made, draw a
line through it and write the words mistaken
entry above or next to the original entry,
with your initials or name so that original
entry remains visible
Avoid writing ERROR when a recording
mistake has been made. This can lead to an
assumption that a clinical error has caused
an injury.
General Guidelines for Recording

Write on every line, not in between

the lines. If a blank space appears in
a notation, draw a line through the
blank so that no additional
information can be recorded at any
other time and by any other person
General Guidelines for Recording

Sequence
Document events in the order in
which they occur.
Update/evaluate problems as
needed.
General Guidelines for Recording

Appropriateness
Record only information that pertains to the
client’s health problem and care.
Completeness
Record all assessments, nursing
interventions, client problems, comments and
responses to interventions and tests,
progress towards goals and communication
with other members of the health team.
 General Guidelines for Recording

Conciseness
Recording needs to brief and
complete
Legal prudence
Accurate, complete documentation
gives legal protection to the nurse
 Dos and Don’ts in Recording

Do’s
Chart a change in the client’s condition
and show that follow up actions were
taken.
Read the nurses’ notes prior to care to
determine if there has been a change
in the client’s condition
DO’s

Record all nursing actions on time. If

in case recording was not done
immediately, bear in mind that a late
entry is better than no entry.
Use objective, specific and factual
prescriptions
DO’s

Correct charting errors

ex. (Clarethromycin) Clarithromycin
-Chart all teaching.
Record the client’s actual words by
putting quotes around the statement.
“Masakit ulo ko” as reported by the client
DO’s

Chart the client’s response to

interventions.
Review notes whether they are
clear and reflect what you want to
say.
Don'ts

Chart in advance of the

event.
Use vague terms.
Chart for someone else
 DON’T’s

Use “patient” or “client”, as it is their

chart.
Leave a blank for colleagues to chart
later.
Alter a record even if requested by a
superior or physician.
Record assumptions or words reflecting
bias.
 REPORT

is oral, written, or

computer-based
communication intended to
convey information to
others.
 Types of Report
A. Change of Shift Report
also termed as ORAL REPORT
ENDORSEMENT and HANDOFF
COMMUNICATION
a report given to all nurses on the
next shift
ENDORSEMENT

The outgoing nurses

give endorsements
to the incoming
nurses
CONTENT OF ENDORSEMENT OR
HANDOVER:

1. Name of Patient – Surname first

2. Age, Sex, Religion (Optional)
3. Attending Physician
4. Diagnosis –Community Acquired
Pneumonia
5. Diet – Diet as Tolerated (DAT)
 6. IVF Rate and Incorporations – with PNSS 1 liter at 30 drops per
minute
 7. Other Contraptions – e.g. with oxygen inhalation via nasal
 cannula at 2 L/min, with on going
 2nd unit of BT PRBC of Blood Type O, serial
 number ________, with
 foleycatheter (FC) attached to urine bag
 (UB) draining to dark yellowish
 urine, with nasogastric tube (NGT)
8. Laboratory Studies – e.g. still for Complete
Blood
 Count (CBC), Plt count q
hours
9. Other Treatment – e.g. For Pulmonary Function
 Test (PFT) at 2 pm today,
 VS q 4, MIO q shift
10. New Orders – e.g. for Sputum Exam tomorrow
11. Latest Vital Signs –T, P, R, BP, O2 Sat
B. Telephone Report

When receiving:
Document the date and time, the name of
the person giving the information and the
subject of the information received, then
sign the notation.
Repeat the message back to the sender to
ensure accuracy.(read-back technique)
 B. Telephone Report
When giving: use SBAR Tool
S=ituation
-State your name, unit, client name.
-Briefly state the problem
B=ackground
medical diagnosis; date of admission; pertinent
medical history; brief summary of treatment to date.
A=ssessment
vital signs change ; pain scale,
R=ecommendation
Have the client’s chart ready to
give primary care provider any
further information.
After reporting, document date,
time and content of the call
 C. Telephone orders

 Write the complete order down and read it back to the primary
care provider to ensure accuracy.
 Question about any order that is ambiguous, unusual or
contraindicated to the client’s condition.
 Transcribe the order onto the physician’s order sheet,
indicating it as a verbal order (VO) or telephone order (TO)
 The order must be countersigned by the primary care
provider within a time period described by agency policy.
SBAR (or ISBAR or ISBARR)

-is a structured method for

communicating critical
information that requires
immediate attention and
action.
I – Identify
S - Situation
B - Background
A - Assessment
R - Recommendation
R - Readback
I – “Hi, I’m Carol, a staff nurse in Acute ward today.”

S – “I would like you to come and see a 21 year old

man who has had a significant skin reaction
 to an antibiotic.”

B- “He was admitted this morning for treatment of an

 appendectomy wound infection. He is a
 type 1 diabetic. He has just had his first dose of
 Gentamicin, Metronidazole and Ampicillin.”
A- “He is anxious and appears flushed
with an erythematous rash on his
chest and arms. His blood pressure
is normal.”

R- “Are you able to see him urgently?”

 “What would you like me to do in the
 meantime?”
D. INCIDENT REPORT
INCIDENT REPORT (IR)

(also called an EVENT REPORT

or OCCURRENCE REPORT)
- is a formal report written by
practitioners, nurses, or other
staff members.
In most healthcare facilities,
injuries, patient complaints,
medication errors, equipment
failure, adverse reactions to
drugs or treatments, or errors in
patient care must be
reported.
Some agencies also report
other incidents, such as the
occurrence of client infection
or the loss of personal be.
When filling out an incident report, include the
following information:

1. the exact time and date;

2. the names of persons involved and any
witnesses;
3. factual information about what happened; and
4. other relevant facts, including your actions (such
as notifying the health care provider) and any
corrective actions taken.
The report should be
completed as soon as
possible and filed
according to agency
policy, usually within 24
hours.
The person who identifies
that the incident occurred
should complete the
incident report.
This may not be the same
person actually involved
with the incident.
EXAMPLE

The nurse who discovers that

an incorrect medication has
been administered completes
the form even if it was another
nurse who administered the
medication.
INCIDENT REPORT FORM I

Client’s Name:
Date of Report:
Date & Time of Incident:
Describe how incident occurred as related
by person injured or person in attendance.
Describe nature and extent of apparent
injury.
Reported by: Reported to Physician:
Time and Date:
Emergency treatment given:
Date: Time:
Signed: _____________________________ M.D.
Steps taken to prevent recurrence of incident:
CI Submitting Report

Name of Institution:
INCIDENT REPORT FORM II

 Name: ______________________________________ Level: ________________

 Area of Assignment: _______________________
 CI: _________________
 Date of Incident: _______________
 A. Describe in detail the event as they occurred.

 B. Action taken:
 __________________________

 Student Signature
REFERRAL SYSTEM

- is defined as the process in

which the primary health care
physician who has lesser facilities
to manage clinical condition
seeks the assistance of specialist
partner with resources to guide
in managing clinical episode.
Referral does not mean
transferring responsibility but
it is sharing responsibility in
patient care.
Factors affecting referrals:

 1. Availability of qualified consultants

 2. Physician specialty
 3. Length of training
 4. Unexplained findings
 5. Uncertainty of diagnosis
 6. Patient characteristics (e.g. attitude of wanting the
best possible care )
 7. Reimbursement plan (e.g. NDU has Insular health
insurance)
Referral Letter Outline:

1. Patient details (name, age, sex and

location)
2. Details of family physician (name of
physician making request and name of
physician being consulted
3. Reasons for referral
4. Degree of urgency for appointment
5. Clinical problem
6. Important previous history
7. Findings on physical examination
8. Findings on investigation
(photocopies of results should be
included)
9. Medication and drug sensitivities
10. Expected outcome and
desirable follow up
Types of Referral:
1. ROUTINE
-Seeking expert opinion for diagnosis and
prognosis (e.g. referring to a pulmonologist
for patient’s cough)
-Seeking hospital admission and
management for the case (e.g. patient
from CRMC being referred to Davao
Doctors’ Hospital)
-Seeking further investigations
2. EMERGENCY
-To reach the expert on time before
occurrence of deterioration with providing all
expected information in referral letter

Usually, the patient is accompanied by a

physician and a nurse in an ambulance after
thorough physical examination and that
patient’s condition can tolerate the travel.
HEALTH CARE
ELECTRONIC
DATABASES
HEALTH CARE ELECTRONIC DATABASES

- are systems into which

healthcare providers routinely
enter clinical and laboratory
data.
DATABASE

- is any collection of data

organized for storage,
accessibility, and retrieval.
HEALTHCARE DATABASE

- serves to replace the

paper documents, file
folders, and filing cabinets.
ELECTRONIC HEALTH RECORDS (EHRs)

- one of the most commonly

used forms of healthcare
databases.
ONLINE TRANSACTION PROCESSING
(OLTP) DATABASE

- most commonly used

type of healthcare
database.
EXAMPLES

-When a patient presents at the

front desk, you search for her name
in the EHR and instantly see a result.
- When you enter the patient’s
blood pressure into the EHR, the
information is instantly stored there.
Practitioners enter routine
clinical and laboratory data
into EHRs during usual practice
as a record of the patient’s
care.
The OLTP database structure
accommodates the creation of a wide
range of transactional applications:
1. EHRs
2. Lab systems
3. Financial systems
4. Patient satisfaction systems
5. Patient identification
6. Administration
7. Billing and payment processing
8. Research
9. HR
10. Education
THANK YOU.
HOPE YOU
LEARNED
SOMETHING.
KEEP ON
LEARNING.