Healthcare Documentation and Reporting

Study Notes

Discussion: An informal oral consideration of a subject by two or more healthcare professionals to identify a problem or establish strategies to resolve it.
Report: Oral, written, or computer-based communication intended to convey information to others.
Record (Chart or Client Record): A formal, legal document that provides evidence of a client's care, written or computer-based.
Recording, Charting, or Documenting: The process of making an entry on a client record.

Date and Time: Should be documented for every entry.
Timing: The frequency of documenting should be consistent and aligned with agency policy.
Legibility: Entries should be easy to read.
Permanence: Use permanent ink that does not smudge or fade.
Accepted Terminology: Use standard medical and nursing terminology.
Correct Spelling: Spell all terms correctly.
Signature: Include name and title for identification.

Objectivity: Record facts and observations rather than opinions or interpretations.
Correction of Mistakes: Draw a line through the mistake, write "mistaken entry" above or next to it, and initial or sign next to the correction (following agency policy).
Completeness: Document on every line, never between lines; if a blank space appears, draw a line through it.

Documents information in the order it occurred, starting with the most recent event first.

Carefully document everything, as it's a legal document that can be used as evidence in court.

Change-of-Shift Report: Given to all nurses on the next shift to provide continuity of care by providing a quick summary of client needs and details of care.

Be concise and accurate.
State name and relationship to client.
State client's name, medical diagnosis, changes in nursing assessment, vital signs related to baseline, significant laboratory data, and related nursing interventions.
Have chart ready to give any further information needed.
Document the date, time, and content of the call.

A meeting of a group of nurses to discuss possible solutions to specific client problems.
Other healthcare providers may be invited to offer their expertise.

Purpose: Two or more nurses visit selected clients at bedside to:
- Obtain information to help plan nursing care.
- Provide clients with an opportunity to discuss their care.
- Evaluate the nursing care the client has received.
Advantages:
- Clients can participate in the discussion.
- Nurses can see the client and the equipment used.
Considerations: Use terms clients can understand.