Documentation

Documentation

Records and reports lay out the key components of the service in such a logical sequence that the new personnel can continue to provide the same level of care to people, families, and communities.

Record

The information pertinent to the client's health care management is recorded in a permanent written communication, such as the clinical chart, which provides a continuous account of the client's requirements and status as a patient. Records serve as a means of communication between family members, other development workers, and health professionals. Keeping records is a crucial feature of nursing practice and is necessary for operating an organization successfully and guaranteeing high standards. The responsibility of an organization's employees to individuals who utilize its services depends heavily on accurate and trustworthy records.

A nursing record is a clinical, scientific, administrative, and legal document that details the nursing care provided to people individually, as a family, or as a community, and that provides the patient's information in the clearest, most condensed manner possible. An successful health record demonstrates the scope of a person's health issues, requirements, and other variables that influence them, as well as their capacity to offer care and their family's beliefs. The records can demonstrate both what has been done and what needs to be done right now. In order to preserve continuity of care, track patient outcomes, and reflect contemporary nursing practice standards, nurses' documentation must be precise, thorough, and adaptable.

Purposes of Recording

Not just members of the health team, but all employees, administrators, and other members can benefit from recording since it offers documentation of the services provided as well as data that is necessary for program planning and assessment.

• Communication: The record serves as the vehicle by which different levels of professionals who interact with a client communicate with each other.
• Planning patient care: Each health professional uses data from the client records to plan care for that client.
• To provide the practitioner with data required for the application of professional services for the improvement of family's health.
• Education: Records can frequently provide a comprehensive view of the client, illness, effective treatment strategies and factors that affect the outcome of the illness.
• Auditing health care agencies
• Research: Information contained in a record can be a valuable source of data for research. The treatment plan for the number of clients with the same health problems can yield information helpful in treating other clients.
• Reimbursement: For facility to obtain payment through medicare, the client's clinical record must contain the correct diagnosis.
• Legal Documentation: The client record is a legal document and is usually admissible in a court as evidence.
• Health Care Analysis: It assists a health care planner to identify agency needs. Health service planning: It provides baseline data to estimate the long-term changes related to services.
• To provide the practitioner with data required for the application of professional services for the improvement of family's health.
• For vital statistics
• Historical documents
• Quality assurance

Administrative Purposes of Clinical Records

• Legal Documents: poisoning, assault, rape, LAMA, burn etc.
• Research or Statistics: rates Audit and nursing audit 
• Quality of care
• Continuity of care
• Informative purposes:
• Teaching purpose of students
• Diagnostic purposes: test reports

Principles of Record

• Nurses should create their own style of expression and record-keeping format.
• Records should be accurately and plainly written.
• Records should be complete, accurate, concise, organized, and timely in accordance with professional and agency standards. They ought to be thorough, precise, well-planned, and timely.
• Facts based on conversation, action, and observation should be included in records.
• Pick a few pertinent facts.
• Records are important legal documents, thus they should be treated with care and kept track of.
• Records should include regular summaries so that future plans may be made and progress can be assessed.
• Immediately following an interview, records need to be entered. Use only recognized abbreviations.
• Subjective data is recorded in quote marks using the client's precise words.
• Information ought to be presented logically.
• The nurses should sign each recording. Name and title are included in the signature.
• Records are private paperwork.

Values and Uses of Record

• Basic information is included in records for services. Records reflect the patient's and family's accepted health state.
• It offers a foundation for analyzing needs in terms of what has been accomplished, what is being accomplished, what needs to be accomplished, and the objectives for which means should be employed.
• It offers a foundation for both short-term and long-term planning.
• It avoids duplication of services and facilitates efficient follow-up care.
• It aids the nurse in assessing the assistance and instruction she has provided.
• It aids in the nurse's efficient use of time and orderly organization of her workload.
• It acts as a roadmap for career advancement.
• It enables the nurse to evaluate the effectiveness and volume of work performed.
• Records assist people in being conscious of and identifying their healthcare requirements.
• A record can also be a useful educational tool.
• Record acts as a manual for diagnosis, treatment, and service evaluation.
• It denotes advancement.
• It might be applied to research.
• Records aid in identifying families in need of assistance and those willing to receive it.
• It allows him to alert the nurse to any important observations he has made.
• The record aids the supervisor in assessing the services provided, the instruction given, and a person's behavior.
• The use of planned records as an evaluation tool during conferences aids in staff and student guidance. 
• It aids the administration in determining the village's or region's health resources and requirements.
• It aids in the creation of studies for research, legislative action, and budget planning.
• It serves as official documentation of the services each employee provided.
• It offers an explanation for the use of money.

Types of Records

Cumulative or Continuing Records

• This is seen to be a time-saving, cost-effective, and useful way to examine a person's whole history and assess their growth over a lengthy period of time, for example, a child's record should have room for neonatal, baby, and preschool data.
• The technique of keeping a single record for both home and clinic visits, with home visits being noted in blue and clinic visits being noted in red ink, aids in service coordination and saves time.

Family Records

• The basic unit of service is the family. All records, which relate to the members of family, should be placed in a single family folder. This gives the picture of the total services and helps to give effective, economic service to the family as a whole.
• Separate record forms may be needed for different types of services such as TB, maternity etc. All such individual records which relate to members of one family should be placed in a single family folder.

Types of Records in Hospital and Community

Administrative 

• Organizational chart
• Policy, rules and regulations
• Nursing procedure manual
• Job description
• Leave form and register
• Attendance register
• Census record
• Stock register
• Condemnation register
• Different administrative format
• Master and Shift rotation chart
• Equipment and supplies form and register

Personnel Records

• Evaluation format: staff, nursing services, nursing program
• Anecdotal records
• Communicative records: application, joining, resign, interview
• Incidental records
• Medical record (health card)
• Minutes of various meeting
• Various committee record and reports
• Guidance and counseling records and reports

Clinical Records

• Census form
• Family folder
• Patient/client file with various records 
• Continuation sheet
• Investigation forms
• Diet form
• Nursing interventions records and reports
• Admission and discharge registers
• Registrations records
• Special records and treatment chart Special monitoring records of the special unit e.g. I.C.U., C.C.U., labor room, neonatal unit, OT, dialysis unit etc. 
• CSSD record forms, mother and child health record cards, family planning record cards etc.
• Referral records

Methods of Documentation

There are several systems for documenting patient information. Each healthcare organization chooses a documentation system that matches its nursing philosophy, whether the paperwork is entered electronically or on paper. Each person on the healthcare team has a responsibility to transmit patient information in an accurate, efficient, and timely way. The same approach may be applied throughout a health care system as well as a specialized organization.

Paper Medical Records: Traditionally, medical personnel kept notes on paper for their patient files. Each patient visit to a healthcare facility is documented separately in paper records, which are episode-oriented. From one episode of care to the next, important details including a patient's allergies, current medicines, and treatment problems may be forgotten.

Electronic Health Records (HER): A patient's health information is recorded electronically every time they get medical treatment in any venue where health care is provided. When and when physicians need it, the HER gives them access to a patient's health record data. No matter how frequently a patient enters the healthcare system, an HER has the ability to combine all relevant patient data into a single record. Additionally, it enhances the continuity of medical care from one illness episode to the next.

The conventional technique for documenting nursing care is narrative documentation. It is simply the use of a narrative structure to record details about patient conditions and nursing care.

A issue-oriented medical record places emphasis on the patient's problem during the recording process. Data are arranged according to an issue or diagnosis. A single list of recognized problems should be contributed to by each member of the healthcare team. A shared care plan is coordinated using this strategy. There are several components in this, such as a database, a problem list, a care plan, and progress notes. The database portion houses all of the patient's evaluation data that is currently accessible. Health care team members identify problems after data analysis and compile a single list of problems. Nurses then create a care plan for each issue. Last but not least, members of the healthcare team track and document the development of patients' issues.

Reports

Reporting is the spoken or written transfer of specified information to an individual or group of individuals. It is the verbal or written communication of information among service providers.

Nursing reports: Written or verbal information about a patient is referred to as a report. A report is a summary of events or observations that were witnessed, carried out, or heard. Reporting includes incident reports, telephone reports, orders, nursing rounds, nursing conferences, and change of shift (handover) reports.

Daily, weekly, monthly, quarterly, and yearly reports can be created. The report outlines the nurse's and/or the agency's services. Reports could take the shape of an analysis of a particular service component. The nurses must keep records of their daily caseload, service load, and activities because these are based on records and registers. This allows for the continuous and lengthy collection of data.

Purposes of Writing Reports

• To show the kind and quantity of service rendered over to a specific period.
• To show the progress in reaching goals.
• To prepare the staff member for their day's work.
• As an aid in studying health conditions.
• As an aid in planning.
• To provide quality and continuity of work from one shift to another.
• To avoid duplication of work
• To interpret the services to the public and to other interested agencies.

Types of Report

Oral Report: Used when the information used is for a short time.

Written Report: Used when the information is to be used for more than one person and is of more permanent values.

In addition to the statistical reports, a nurse should write a narrative report every month which provides an opportunity to present problems for administrative considerations. Maintaining records is time consuming, but it is of definite importance today in the community health practice in solving its health problems.

Different Forms of Reports

• Change of shift report
• Telephone reports
• Transfer reports
• Incident reports
• Legal reports

Phases of Record and Reports

Preparation Phase: Writing and recording of facts clearly, completely, correctly and concisely in simple language.

Compiling Phase: Systematic and correct compilation of records and reports with confidentiality.

Storing Phase: Storing and preservation of all compiled records/reports safely with proper manner. It should be available and accessible at any time. Storing and handling of record should be done by trained personnel and confidentiality should be maintained.

Discarding Phase: All the records and reports need to be discarded routinely as per the policy of the individual organization. Disposing and discarding of the reports should be done by authorized committee of the institution/ organization.

Guidelines/Principles for Documentation of Recording and Reporting

The basic guidelines for good practice in documentation and record keeping apply equally to written records and to computer-held records.

• Create record forms with a precise, succinct, clear, and particular structure, and provide enough.
• Inform the personnel about the different record formats and forms.
• Records and reports should be accurate and consistent, and they should be based on facts.
• To give current information about the patient's or client's care and condition, it should be written as soon as possible after an event.
• It needs to be written legibly and in a way that it cannot be changed.
• In order to preserve the clarity of the original entry, it should be written so that any modifications or additions are timestamped, dated, and signed.
• It should be legibly timed, signed, and duly dated, with the signature appearing next to the first entry.
• Abbreviations, jargon, pointless phrases, unrelated speculation, and offensive subjective statements are not appropriate.
• Any photocopies should be able to reproduce it.
• Wherever feasible, the patient, client, or their carers should be included in the writing process.
• It must to be written in language that the client or patient can comprehend.
• It ought to be in order.
• It should offer unambiguous proof of the planned care, the decisions made, the care actually provided, and the information shared.
• Create a simple or easy monitoring system for reporting, recording, and nursing.
• Nurses should refine their own style of expression and record-keeping form.
• Facts based on conversation, action, and observation should be included in records.
• The chosen pertinent information should be recorded neatly, completely, and consistently.
• Records should include periodic summaries so that decisions can be made about the future and progress.
• Immediately following an interview, records need to be entered.