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Importance of Staff Communication in Nursing Care Documentation

Learn about nursing communication methods, client record purposes, documentation systems, guidelines for recording, and reporting in healthcare settings. Effective communication enhances care quality.

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Importance of Staff Communication in Nursing Care Documentation

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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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