Chapter 9 Recording and Reporting

1. Chapter 9Recording and Reporting

2. Medical Records • Recording referred to (process of writing information) • Other words (Reporting, Documenting, Charting, and Recording) . • Medical (health) records are written collections of information about a person’s health, the care provided by health practitioners, and the client’s progress • Also known as health records or client records (files)

3. Uses of Medical Records • Permanent account • The record is filled and maintained for future references. • Sharing information • Continuing of care. • Prevent duplication or omission • Quality assurance • Continues quality improvement. • To improve the quality of care. • Accreditation (Official Approval) • Reimbursement (To pay the coasts of documented care). • Education and research • Legal evidence

4. Components of Medical Records Person’s health information Care provided by health practitioners The client’s progress The plan for care Medication cycle

5. Types of patient's records • Source-Oriented Records • Organized according to source of documented information • Contain separate forms for physicians, nurses, dietitians, physical therapists to make written entries about their specific activities in relation to client’s care • This record provides fragmented documentation • Consider of traditional type of record

6. Problem-Oriented Records • Organized according to client’s health problems • Four major components: data base, problem list, plan of care, progress notes • Information arranged to emphasize goal-directed care; promote recording of pertinent information; facilitate communication among health care professionals

7. Components of Problem-Oriented Records

8. Methods of Charting • Narrative charting • Style of documentation generally used in Source-Oriented Records. • Involve writing information about the patient and patient's care in a chronologic order. • SOAP charting • Style of documentation more likely to be used in a Problem-Oriented Record. • S = Subjective Data. • O = Objective Data.. • A = Analysis of the Data.. • P = Plan for care. • Some agencies have expanded the SOAP format to SOAPIE or SOAPIER • I = Interventions • E = Evaluation • R = Revision to the plan of care

9. Methods of Charting (cont’d) • Focus charting (DAR model is used ) • D = Data A = Action R = Response • PIE charting • P=Problem I=Intervention E=Evaluation • Charting by exception • Method in which only abnormal assessment finding are written. • Computerized method • Documenting patient information electronically

10. DOCUMENTING INFORMATION • Abbreviations • Abbreviations shorten length of documentation and documentation time • Agencies provide list of approved abbreviations and their meanings • Use only abbreviations on agency’s approved list

11. DOCUMENTING INFORMATION (cont’d) • Documentation Time • Traditional time • Two 12-hour revolutions; identified with hour and minute, followed by a.m. or p.m. • Military time • Based on 24-hour clock; uses different four-digit number for each hour and minute of the day • First two digits indicate hour within 24-hour period • Last two digits indicate minutes

12. Documentation Time (cont’d)

13. Charting Guidelines • Should not be time-consuming to write and read • Everyone involved in the care of a client should make entries in the same location in the chart • The nurse should address specific content in charted progress notes • Assessments should be documented on a separate form • Information should always be clear

14. Charting Guidelines (cont’d) • Abnormal assessment findings, or care that deviates from the standard, should also be documented separately • Client information should be documented electronically • Abbreviations and terms should be consistent with agency-approved lists • The date of the documentation should be recorded • The time of the documentation should be recorded

15. Written Forms of Communication Nursing care plan: list of client’s problems, goals, and nursing orders for client care Nursing Kardex: quick reference for current information about client and client care Checklists: documentation with check mark or initials Flow sheets: documentation with sections for recording frequently repeated assessment data

16. Other Forms of Communication Change of shift reports: Discussion between a nursing spokes person from the shift that is ending and personnel coming duty. Client assignments: Are made at the beginning of each shift. Team conferences :Are commonly used for exchanging information Rounds : Visit to patients on an individual basis or as group Telephone calls

17. Nursing Documentation