Documentation and reporting

Documentation

— Essential form of communication

— Provides relevant, accurate, up-to-date information

— To make safe clinical decisions

Source oriented record

— Narrative recording by each member of the healthcare team on separate records

— Consists f written notes that include routine care, normal findings and client problems

• Admission sheet

• Nurses notes

• Diagnostic reports

• Special flow sheets

Problem oriented medical record

— Method of documentation focusing on specific health problems

— 4 basic components

• Database

• Problem list

• Initial plan

• Progress notes

PIE

— Problems, interventions and evaluation of care

— Eliminates the traditional care plan

— Incorporates an ongoing care plan into the progress notes

Focus charting

— Method of identifying and organizing the narrative documentation of patient concerns and strength

— FDAR

Charting exception

— Only abnormal or significant finding or exceptions to norms are recorded

Computerized documentation

— Record the patient’s assessment, medication administration

Electronic health records

— Manage huge volume of information

Case management

— Emphasizes quality, cost effective care

Variance

— Unexpected occurences that affect the planned of care or the client’s response to care

Admission nursing assessment

— Completed when the client is admitted to the nursing unit

Nursing care plan

— There should be and evidence f client assessment, nursing diagnosis, interventions, outcomes

Kardexes

— Makes information quickly accessible to all health professionals

Flow sheets

— Graphic records, intake and output monitoring, medication administration record

Progress notes

— Provide information about the progress of a client

Nursing discharge / referral summaries

— Completed when the client is being discharged and transferred to another institution

Care plan conference

— a meeting of a group of nurses to discuss possible solutions to certain problems of a client

Nursing rounds

— Procedures in which two or more nurses visit selected clients