NURSING RECORDS

AND REPORTS

ADALARASAN.V

DEFINITION OF REPORTS:Reports are oral or written exchanges of

information shared between caregivers or
workers in a number of ways.
B.T
Basavanthappa
DEFINITION OF RECORDS:A record is a permanent written
communication that documents
informations relevant to a clients health
care management.
B.T
Basavanthappa

PURPOSES OF RECORDS:Communication:-The record is a means by

which health team members communicate
contributions to the clients care.

Education:- .Students of nursing ,medicine

and other health related disciplines use
these records as an educational resource. An
effective way to learn the nature of an
illness and the response to it is to read
the medical record.

Assessment:-The record provides data for

nurses to use to nursing diagnosis and plan
proper interventions for care The record
provides a total picture of the clients health
status. The record contains data to explain
and confirm observations or refute
interpretations.
Research:-A nurse may use clients records
during a research study to collect
information on certain factors.
Nurses may also research records of
previously discharged clients to identify
nursing care problems.

Auditing:- Nurses conduct audits of records

throughout the year to determine the degree
to which quality assurance standards are
met. Deficiencies identified during audits are
shared with all members of the nursing staff
so corrections in policy or practice can be
made.

Legal Documentation:-A medical record

must be accurate because it is a legal
document. The record serves as a
description of exactly what happened to a
client.

GUIDELINES FOR GOOD REPORTING AND

RECORDING:ACCURACY:Information about clients and their care
must be correct. Factual information is less
likely to be misleading or to cause
misinterpretation.
CONCISENESS:Concise data are easy to
understand. Clear, succinct recording and
reporting gives only essential information
and avoids the use of unnecessary words or
irrelevant detail.

THOROUGHNESS:A good report or record is

thorough, with complete information
about a client. The nurse will make
written entries in the clients medical
record, describing nursing care
administered and the clients response.
CURRENTNESS:Delays in recording or reporting can
result in serious omissions and untimely
delays for needed care. Decisions about a
clients care are based on currently
reported information. Activities that must
be communicated at the time

ORGANIZATION:The nurse communicates information

in a logical format or order. The organized
note describes the clients pain, nurses
assessment and physicians order in a
logical order of occurrence.
CONFIDENTIALITY:
A confidential communication is
information given by one person to another
with trust and confidence that such
information will not be disclosed. All health
team members must keep confidential any
information noted in the record and avoid
repeating what is heard from other staff
members who might reveal a diagnosis to
others or discuss a client with other clients.

RECORDS
Good documentation reflects not only
quality of care but evidence of each health
care members accountability in giving care.
PATIENT RECORD:The patient record is a compilation
of patients health information. The Joint
Commission on Accreditation Of Health Care
Organizations (JCAHO,2006) specifies that
nursing care data related to patient
assessments, nursing diagnoses or patient
needs, nursing interventions, and patient
outcomes are permanently integrated in to
the patient record.

Patient record serve many

purposes, such as communication with
other health care professionals,
recording of diagnostic and therapeutic
orders, care planning, quality of-care
reviewing ,research, decision
analysis,education,legal
documentation, reimbursement and
historical documentation.

METHODS OF RECORDING:SOURCE RECORDS:- In a source record

the clients chart is organized so each
discipline has a separate section in
which to record data.
Advantage
Care givers can easily locate the
proper section of the record in which to
make entries.
Disadvantage
Information is fragmented.

PROBLEM- ORIENTED MEDICAL

RECORDS:The problem-oriented medical record
is a structured method of documentation
that places emphasis on the clients
problems. With the POMR the clients
problems are easy to recognize and
locate, data are well coordinated, and
each discipline records progress notes
on the same form. The client benefits
from his charting method because all
health care team members contribute to
a common, coordinated plan or care.

Advantages of POMR charting method: Places emphasis on clients and their

problems.
Increase efficiency in gathering data about
clients from all health care givers.
Gives emphasis to clients perceptions of
their problems.
Requires continuous evaluation and
revision of plan of care.
Provides greater continuity of care
between health care between health care
team members.
Enhances effective communication among
health care team members.

The POMR has the following major

sections: data base, problem list,
initial plan and progress notes.
1)DATA BASE:This section contains all available
assessment information pertaining to the
client. The data base provides a foundation
for identifying client problems and planning
an effective course of action.
2) PROBLEM LIST:Once data are analyzed,
Problems are identified and a single list is
made. The problems are listed in
chronological order according to the date
each was identified.

The list of problems is filed in the

front of the clients record to serve as
an organizer or table of contents. New
problems are added as they are
identified. Once a problem has been
resolved, the date of resolution is
recorded and a line is drawn through
the problem and its number on the
problem sheet.

3) INITIAL PLAN:-An initial plan is

developed for each active problem
identified. There are three parts of a plan;
a) Diagnostic workup:-The physician
indicates what diagnostic studies should
be initiated first.
b) Proposed therapy:-The physician
orders specific therapies by problem.
c) Client education:-Identifying the
clients educational needs, address the
long term implications of illness. Health
team members identify the types of
information or skills required by a client
to adapt to any health related problems.

4) PROGRESS NOTES:- Health team

members must monitor and record the
progress of a clients problems.
Progress notes follow a special format
(eg SOAP), so information is
communicated clearly to all who read
them. SOAP is an acronym for
subjective data, assessment and plan.
The logic for SOAP notes is similar to
that of the nursing process.

MODIFIED PROBLEM-ORIENTED
MEDICAL RECORDS:At the time of clients admission,
an initial nursing assessment identifies
the nursing diagnosis. The diagnosis
are dated and numbered in order of
occurrence or by priority on the basis
of the initial assessment. The nurse
then lists the number each time the
problem is recorded in the SOAP or PIE
notes. Once the diagnosis is resolved
the nurse enters the date, notes that
the problem is resolved and initials it.

FORMATS FOR NURSING

DOCCUMENTATION:INITIAL NURSING ASSESSMENT:A typical form used to record the initial
database obtained from the nursing history and
physical assessment. Accurate documentation of
these data is important
KARDEX AND PATIENT CARE SUMMARY
Folded card is placed in central kardex file where it
is easily accessible.
The outside of the card contains basic information.
The inside of the kardex contains the nursing care
plan specifying nursing diagnosis and health
problems.
.

PLAN OF NURSING CARE:The plan of nursing care may be

written separately into a
multidisciplinary plan. In a traditional
plan of nursing care, nursing diagnosis,
goals and expected outcomes and
nursing interventions are written for each
patient.
CRITICAL/COLLABORATIVE PATHWAYS:The case management
plan is detailed, standardized plan of care
that is developed for a patient population
with a designated diagnosis or procedure.

PROGRESS NOTES:The purpose of

progress note is to inform caregivers of
the progress a patient is making
toward achieving expected outcomes.
FLOW SHEETS:Flow sheets are
documentation tools used to record
routine aspects of nursing care

GRAPHIC (CLINICAL) RECORD:The graphic sheet is a form

used to record specific patient variables
such as pulse, respiratory rate, blood
pressure readings, body temperature,
weight, fluid intake and output, bowel
movements and other patient
characteristics.
24-HOUR FLUID BALANCES RECORD:Forms are available to document
the 24-hour intake and output of fluids
for patients with special needs.

MEDICATION RECORD:The patients medication

record must include documentation of
all the medications administered to the
patient (drug, dose, route, time)
24-HOUR PATIENT CARE RECORDS
AND ACUITY CHARTING FORMS:Twenty-four- hour reports
are increasingly used in conjunction
with acuity reports, which allow nurses
to rank patients as high to low acuity

DISCHARGE AND TRANSFER SUMMARY:At the time a patient is

discharged from care or transferred from
one unit or institution or agency to
another, a clinical report should be
written that concisely summarizes.
HOME HEALTHCARE
DOCCUMENTATION:Documentation of home care visits
that reports the patients progress serves
multiple purposes. Sent to the attending
physician with a request for signed
medical orders to continue treatment,
these records ensure continuity of care.

LONG-TERM CARE
DOCCUMENTATION:Documentation in long-term
care settings is specified by the
Resident Assessment
Instrument(RAI),which helps staff
gather definitive information on a
residents strengths and needs, and
addresses these in an individualized
plan of care.

ALTERNATIVE RECORD-KEEPING
FORMS:NURSING HISTORY FORMS:The form usually contains basic
biographical data,a brief history, the
clients perceptions about illness or
hospitalization, and a physical assessment
of all body systems.
FLOW SHEETS: To record specific measurements or
observations that occur on a repeat.
It can show important clinical trends
graphically without the nurse or physician
having to locate the source information in
several notes.

NURSING KARDEX:-

Information commonly found in the

kardex includes the following:
Basic demographic data
Primary medical diagnosis
Current physicians order to be carried out
by nurse
A written nursing care planNursing orders
Scheduled tests and procedures
Safety precautions to be used in the
clients
Factors related to activities of daily living

TIPS ON WRITING KARDEX CARE

PLANS:WHEN TO WRITE A CARE PLAN;
During a report as nurses discuss client
problem and needs.
On rounds after client problems are
identified and reviewed
After discussions with other health
team member responsible for client
care.
After interactions with the client and
family members.

WHAT TO INCLUDE;
nursing assessment data
Nursing diagnosis
Nursing orders
Expected outcomes of nursing care.

STANDARDIZED CARE PLANS:The plans, based on the institutions

philosophy of nursing care, are
preprinted, established guidelines
used to care for clients with similar
health problems.

ADVANTAGES OF STANDARDIZED CARE

PLANS: Establishment of clinically sound standards
of care for similar groups of clients.
Standardized plans are easy to locate in a
clients record, and thus all staff can
quickly refer to the plan of care.
Another advantage is education. Nurses
learn to recognize the accepted
requirements of care for client.
The standardized plans can also improve
continuity of care among professional
nurses.
Documentation takes less time

DISADVANTAGES OF STANDARDIZED
CARE PLANS: Standardized plans inhibit nurses
identification of unique, individualized
therapies for client.
There is need to formally update the
plans on a routine basis to ensure that
content is current and appropriate.

DISCHARGE SUMMARY FORMS:Ideally discharge planning begins at

the time of a clients admission. Nurses
revise the plan as the clients condition
changes. The client should have the
necessary information and resources to
return home.

TIPS TO WRITING DICHARGE SUMMARY

FORMS:INFORMATION FOR HOME HEALTH CARE
NURSES: Describe nursing interventions(eg dressing
changes, step-by-step wound care)
Describe information presented to client.
Describe clients ability to perform health
care skills.
Explain family members involvement in
care.
Describe resources needed in the home

INFORMATION FOR CLIENTS: Use clear, concise descriptions in clients

own language.
Explain step-by-step description of how
to perform a procedure. Reinforce
explanation with printed instructions.
Identify precautions to follow when
performing self-care or administering
medications.
Review signs and symptoms of
complications that should be reported to
physician.
List names and phone numbers of health
care providers the client can contact.

COMPUTERIZED
DOCCUMENTATION:Nurses should be familiar with
basic computer skills because most
hospitals now have some form of
automated system. Hospitals have
large mainframe computer systems or
individualized personal computers.

POTENTIAL LEGAL PROBLEMS IN

DOCCUMENTATION:Documentation content that
increases risk for legal problems: The content is not in accordance with
professional or health care
organization standards.
The content does not reflect patient
needs.
The content does not include
descriptions of situations that are out
of the ordinary.

 The content over generalizes patient

assessment or nursing interventions.
The content is incomplete or
inconsistent.
The content does not include
appropriate medical orders.
The content implies a potential or
actual risk situation.
The content implies attitudinal bias.

DEFINITION
A large amount of information is
exchanged between health care team
members.
PURPOSES OF REPORTING: To show the kind and amount of services
rendered over a specified period.
To illustrate progress in reaching goals.
As an aid in studying health conditions.
As an aid in planning.
To interpret the services to the public
and other interested agencies.

TYPES OF REPORTS MADE BY

NURSES:Change-of-Shift reports:These may be given orally in
person by audiotaping,recording or
during rounds at the clients bedside.
Provide only essential background
information about client (name, sex,
age, diagnosis and medical history).
Identify clients nursing diagnosis or
health care problems and other related
causes.

Describe objective measurements

or observations about clients condition
and response to health problem.
Share significant information about
family members as it relates to clients
problem. Continuously review ongoing
discharge plan. Dont engage the idle
gossip.
Relay to staff significant changes in
the way therapies are given. Do not
describe basic steps of a procedure.

Describe instruction given in teaching

plan and clients response, do not
explain detailed content unless staff
members ask for clarification.
Evaluate results of nursing or medical
care measures .Do not simply
describe results as good or poor. Be
specific.
Be clear on priorities to which
oncoming staff must attend. Do not
force oncoming staff to guess what to
do first.

 Telephone reports:Information in a telephone

report may not be permanently
documented in a written form. Thus
the persons involved with a telephone
report should be sure the information
is clear, accurate and concise.

 Telephone techniques: Incoming calls: yourself to smile before picking up the

phone.
Identify the nursing division and
yourself
Be natural. Use your real voice, tone
and volume.
Treat each all as important.
Give the caller your full attention
Listen carefully.
Use words of courtesy and politeness.

 Takes notes as pertinent information is

communicated.
If there are any questions, ask them
after the caller has finished speaking.
End the call graciously.
Let the caller hang up first.

Outgoing calls: Place your call

When the other person answers,
identify yourself.
Use the persons name. State why you
are calling.
If the report is lengthy, have notes
infront of you.
Ask the other person if he has any
other questions.
End the call graciously

While incident reporting the

following points are to be kept in
mind:The report is submitted as soon as
possible to the nurse who witnessed
the incident
The nurse describes in concise what
happened specifically objective terms
etc.
The nurse does not interpret or
attempt to explain the cause of the
incident.

The nurse describes objectively the

clients, conditions when the incident
was discovered.
Any measures taken by the nurse,
other nurses, or doctors at the time of
the incident are reported.
No nurse is blamed in an incident
report.
Appropriate authority.
The nurse should never make the
photocopy of the incident report.

TRANCFER AND DISCHARGE REPORTS: When giving transfer request, nurse

should include the following information;
Clients name, age, primary doctor, and
medical diagnosis.
Summary of medical progress up to the time
of transfer.
Current health status-Physical and psychosocial.
Current nursing diagnosis or problems and
care plan.
Any critical assessment or interventions to be
completed shortly.
Needs for any special equipment etc.

LEGAL REPORTS:In such reports, the content is

stated briefly and objectively giving all
pertinent information. Accuracy,
timeliness, completeness and
relevancy to the problems are
maintained promptly while making
such reports.

SUMMARY
CONCLUSION
ASSIGNMENT
THEORY APPLICATION
BIBLIOGRAPHY