Healthcare Documentation and Reporting

Documenting and Reporting

• 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.

Purposes of Client Records

• Communication
• Planning client care
• Auditing health agencies (quality)
• Research
• Education
• Legal documentation
• Health care analysis (agency planning)

General Guidelines for Recording

• 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.

Accuracy

• 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.

Sequence

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

Appropriateness

• Document only information relevant to the client's care.

Conciseness

• Use concise and clear language.

Legal Caution

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

Reporting

• 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.

Guidelines for Receiving a Telephone Report

• Document date and time.
• Record the name of the person giving the information.
• Record the subject of the information received.
• Sign the notation.
• Repeat information to ensure accuracy.

Guidelines for Giving a Telephone Report

• 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.

Care Plan Conference

• 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.

Nursing Rounds

• 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.