C C C M MMMM MM M MMM 3mm MMMMM MM M MMMMM

DOCUMENTING AND REPORTING

 Documentation serves as a permanent record of client information and care.

 Reporting – takes place when two or more people share information client care, either face to
face or by telephone.
Purposes of Client’s Record/Chart

1. Communication – provides efficient and effective method of sharing information

2. Legal Documentation – it is admissible as evidence in the court of law
3. Research – provides valuable health-related data for research.
4. Statistics – provides statistical information that can be utilized for planning people’s future
needs.
5. Education – serves as an educational tool for students in health discipline.
6. Audit and quality assurance – monitors the quality of care received by the client and the
competence of health care givers.
7. Planning client care – provides data which the entire health team uses to plan care for the client
8. Reimbursement – provides the basis for decisions regarding care to be provided and
subsequent reimbursement to the agency, to cover health-related expenses.
Types of records
A. Source oriented Medical Record ( Traditional Client Record )

 Each person of department makes notations in a separate section of the client’s chart.
Five Basic Components of the Traditional Client Record
1. Admission sheet
2. Physician’s order sheet
3. Medical history
4. Nurse’s notes
5. 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 )

 Data about the client are recorded and arranged according to the source of the information.
Four Basic Components of POMR/POR
1. Database – contatins all the initial information about the client

2. Problem list – contains all the aspects of the person’s life requiring healthcare.
3. Initial list of orders or care plans.
4. Progress notes:
 Nurse’s or narrative notes ( SOAPIE format)
S – Subjective data
O – Objective data
A – Assessment
P – Planning
I – intervention
E - Evaluation
 Flow sheets ( data that are monitored )
 Discharge notes or referral summaries
Kardex
 Provides a concise method of organizing and recording data about a client, making
information readily accessible to all members of the health team.
 It is a tool for change – of – shift report. But endorsement is not simply reciting content of
kardex. The health care need of the client is still primary basis for endorsement.
 Kardex usually includes the following data:
- Personal data ( demographic data )
- Basic needs
- Allergies
- Diagnostic test
- Daily nursing procedures
- Medications and intravenous (IV) therapy, blood transfusion
- Treatments like oxygen therapy, steam inhalation, suctioning, change of
dressings, mechanical ventilation
Characteristics of Good Recording
1. Brevity
 Complete sentences are not required.
 Start each entry with a capital letter and end the entry with a period even if the entry is
single word or phrase.
2. Use of ink/permanence
 Avoid felt pen or pencil for permanence of data, because the client’s chart used as
evidence in a legal court.
3. Accuracy
 Chart objectives facts, not your own interpretations or opinions.
E.g Correct: Refused medications.
Incorrect: uncooperative
4. Appropriateness
 Only information that pertain to the client’s health problems and care recorded.
5. Completeness and chronology/organization/sequence/timing
 Continuous charting is done for each entry unless a time change occurs
 Date is entered in the date column on the first line of every page of nurse notes and
whenever the date changes.
 Avoid double chart.
The following information should be charted:
 Physician’s visit
 Times the pateint5 leaves and returns to the unit, mode of transportation and
destination.
 Medications should be charted immediately after given.
 Treatments should be charted immediately after given.
6. Use of standard terminology.

 Use only those abbreviations and symbols approved by the institution; spell correctly;
use of proper grammar.
7. Signed
 Affix signature, place at the end of the charting, at the right hand margin of the nurse’s
notes.
 Sign each entry with full name and status
8. In case of error
 Correct errors by drawing single (horizontal ) line through the error.
 Write the word error above the line, and then sign your signature.
9. Confidentiality
 Only health personnel who participate in the care of the client are allowed to read he
chart.
10. Legal awareness
 Chart only what you personally have done, observed, heard, smelled, or felt.
 Do not discard any part of the client record.
11. Legible
 Writing must be clear and easily read by others
12. Do not use the word “patient” or “pt” in the chart; the chart belongs to the patient. All
information in the chart pertains to the patient.
13. A horizontal line is drawn to fill up a partial line. This is to prevent other persons from adding
information in the nurses’ notes.
REPORTING
1. Change – of – shift reports or endorsement.

 For continuity of care
 It s based on health care needs of the client.
2. Telephone orders
 Provide clear, accurate, and concise information.
 The nurse documents telephone report by including the following information:
a. When the call was made.
b. Who made the call/report.
c. Who was called.
d. To whom information was given.
e. What information was given.
f. What information was received.
3. Telephone orders
 Only the RN’s may receive telephone orders
 The order needs to be verifies by reporting it clearly and precisely.
 The order should be countersigned by the physician who made the order within
prescribed period of time (within 24 hours).
4. Transfer reports
This is done when transferring a client from one unit to another.
Teaching and learning (Client Education/Patient Teaching)
Learning
 A change in human disposition or capability that persists over a period of time.
Theories of Learning
 Behaviorism – transfer of knowledge

 Cognitism – learning is a complex cognitive (intellectual) activity.
 Humanism – there is a natural tendency for people to learn and that learning flourishes in an
encouraging environment.
Source: Mastering fundamentals of nursing third edition by Josie Quiambao-Udan, RN, MAN

C C C M MMMM MM M MMM 3mm MMMMM MM M MMMMM

Uploaded by

Copyright:

Available Formats

C C C M MMMM MM M MMM 3mm MMMMM MM M MMMMM

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

C C C M MMMM MM M MMM 3mm MMMMM MM M MMMMM

Uploaded by

Copyright:

Available Formats

What are the different types of client records discussed?

What are some characteristics of good recording in client records?

DOCUMENTING AND REPORTING

 Documentation serves as a permanent record of client information and care.

Purposes of Client’s Record/Chart

1. Communication – provides efficient and effective method of sharing information

A. Source oriented Medical Record ( Traditional Client Record )

Five Basic Components of the Traditional Client Record

B. Problem-Oriented Medical Record ( POMR or POR )

Four Basic Components of POMR/POR

1. Database – contatins all the initial information about the client

Characteristics of Good Recording

The following information should be charted:

6. Use of standard terminology.

1. Change – of – shift reports or endorsement.

Teaching and learning (Client Education/Patient Teaching)

 A change in human disposition or capability that persists over a period of time.

 Behaviorism – transfer of knowledge

You might also like