Documenting and Reporting PDF

Documenting and Reporting By Dr. Zyad Saleh  Documenting and Reporting discussion 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. Report: oral, written, or c...

Documenting and Reporting By Dr. Zyad Saleh  Documenting and Reporting discussion 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. Report: oral, written, or computer based communication intended to convey information to others. record (chart or client record): a formal, legal document that provide 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 Timing (frequency of documenting) Legibility (easy to read) Permanence Accepted terminology Correct spelling Signature (e.g. name and title) General Guidelines for Recording –con. Accuracy – notations consist of facts or observations rather than opinions or interpretations. – When recording a mistake, draw a line through it and write the words mistaken entry above or next to the original entry, with your initials or name (agency policy) – Write on every line but never between lines – For a blank appears in a notation, draw a line through the blank space.  Sequence Appropriateness Conciseness Legal Caution  Reporting Change-of-Shift Report Given to all nurses on the next shift To provide continuity of care for clients by providing the new caregivers a quick summary of client needs and details of care to be given. May be written or given orally  Guidelines for Receiving a Telephone Report Document date and time Record the name of 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 the client’s name, medical diagnosis, changes in nursing assessment, vital signs related to baseline, significant laboratory data, 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 certain problems of a client Other health care providers may be invited to offer their expertise  Nursing Rounds Two or more nurses visit selected clients at bedside to: – Nurses obtain information that will help plan nursing care – Provides clients opportunity to discuss their care – Evaluate the nursing care the client has received Advantages: – Clients can participate in discussion – Nurses can see the client and used equipments. Need to use terms client can understand