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Documenting and reporting

Documenting and reporting. Pages 104-111 Prepared by: Dr.Reem A.Jarrad. Why communication between staff is important?. Because it enhances quality and continuity of clients care. Definitions of nursing communication methods.

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Documenting and reporting

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  1. Documenting and reporting Pages 104-111 Prepared by: Dr.Reem A.Jarrad

  2. Why communication between staff is important? • Because it enhances quality and continuity of clients care

  3. Definitions of nursing communication methods • 1- Discussion: is an informal oral consideration of a subject by two or more health professionals to identify a problem or to develop strategies to resolve one.

  4. Definitions of nursing communication methods • 2- Report: is oral, written or computer based communication intended to convey information to others.

  5. Definitions of nursing communication methods • 3- record : is a written or computer based documentation( charting or recording).

  6. What are the purposes for using client records? • 1- Communication • 2- Planning client care • 3- Auditing health agencies ( quality assurance) • 4- Research • 5- Education • 6- Legal documentation • 7-Health care analysis( SWOT= strengths, weaknesses , opportunities, and threats)

  7. Documentation Systems • 1- Source oriented record • 2- Problem oriented medical record • 3- Pie ( problems, interventions and evaluation) • 4- Focus Charting • 5- Computerized documentation • Note : practice tips for documentation on the bottom of page 108).

  8. General Guidelines for recording • 1- Date and time • 2- Frequency of documenting according to policy and client condition • 3- Legibility ( easy to read..) • 4- Permanence ( dark ink) • 5- Accepted Terminology • 6- Correct spelling

  9. General Guidelines for recording • 7- Signature • 8- Accuracy ( how to manage wrong entry?) • 9- Sequence (order of occurrence) • 10- Appropriateness ( relevant client data only) • 11-Conciseness ( Brief recording) • 12- Legal caution( look nursing note page 107, right upper border, directly above word reporting)

  10. Reporting • Definition: • to communicate specific information to a person or group of people, whether oral or written.

  11. Examples for Reporting • 1- Change of Shift Reports • 2- Telephone reports • 3- Care Plan Conference • 4- Nursing Rounds • (Pages 107-108)

  12. Good luck with first exam • - Which will be on the 28-10-2014 • The same time and place of the lecture. • - Two value- ethics lectures will remain after the exam, and will be included in the second exam Your Tutor

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