14-Documenting, Reporting

& Conferring &Using Informatics

(452)
• Effective communication among health care
professionals is essential to the coordination
and continuity of person-centered care.

• Communicating effectively enables personnel

to support and to complement one another’s
services and to avoid duplications and
omissions in care.
 Documenting Care
• Documentation is :

• The written, or electrical records of all

pertinent interactions with the patient-
assessing, diagnosing, planning, implementing
and evaluating.
 Documenting Care
• The data are used to:
1-Facilitate quality.
2-Evidenced –based patient care.
3-Serve as a financial and legal record
4-Help in clinical research.
5-Support decision analysis.
 The Patient Record
• Is a compilation of a patient’s health
information, each health care institution or
agency has policies that specify nurse’s
documentation responsibilities.
 Guidelines for Effective Documentation

• The pt record is the only permanent legal

document that details the nurse’s interactions
with the pt.

• It is the nurse’s best defense if a pt or pt

surrogate alleges nursing negligence.
• The ANA standards identify the following
characteristics of effective documentation:
1-Accessible
2-Accurate
3-Relevant
4-Consistent
5-Auditable
6-Clear
7-Concise
8-Complete
9-Legible/readable
10-Thoughtful
11-Timely
12-Contemporaneous,( up to date)
13-Sequential
14-Reflective of nursing process
15-Retrievable on a permanent basis in a
nursing- specific manner.
 Privacy & Confidentiality
• Nurses and other professional caregivers learn
and communicate private information about
pts and their families every day.
• So what information is confidential?
• All information about pts are considered
private or confidential whether written on
papers, saved on computers or spoken aloud.
• ( pt’s name, address, phone, fax and many
other things are considered private.
 Health Information Privacy
• The U.S Officer for Civil Rights enforces the
Health Insurance Portability & Accountability
Act ( HIPAA) privacy rules, which protects the
privacy of individually identifiable health
information.

• The HIPAA security rules, which sets national

standards for the security of electronic
protected health information.
 The Patients Have Rights to
1-See and copy their health records
2-Update their health records
3-Get a list of the disclosures that a health care
institution has made independent of disclosures
made for the purposes of treatment, payment,
and health care operations.
4-Request a restriction on certain uses or disclosures
5-Choose how to receive health information.
 Agency Policy

*Most agencies have specific policies regarding

patient’s records.
*Everyone with access to the records (direct
care giver) is expected to maintain
confidentiality
*Most agencies grant student nurses access to
patient records for education purposes..
*Also the policy indicates which personnel are
responsible for recording on each form in the
record.
*The storage of patient record after treatment is
a function of the health agency’s record
department
*Many records are microfilmed for compact
storage or are entered into a computer to
expedite accessibility of information.
 Purposes of Patient Records:
1-Communication.
• The pt’s record helps healthcare professionals

from different disciplines who interact with the

patient at different times to communicate with

one another.
 2- Diagnostic and Therapeutic Orders.

• Anyone reviewing the chart can find all the

diagnostic studies ordered for the pt since the
admission, also the result of these diagnostics
and any related orders for care.
• Illegible hand- written notes and typos have
been the source of many of many errors.
 Verbal Orders
• In many agencies the diagnostics and therapeutic
orders should be accepted and executes only
when written and signed by the member of the
house or professional staff who is issued the
orders, except in medical emergencies.

• The order must be given directly,

• Read back means the nurse should read the order
to the person who ordered to prevent errors.
 3-Care planning

• Writing the care plan and doing modifications

by the person who works with the pt and

watch his progress.

 4-Quality Process & Performance
Improvement
(Documentation is the primary source of
evidence used to continuously measure
performance outcomes against predetermined
standards)
• Records may be reviewed to evaluate the
quality of care patients have received and
competence of the nurses providing that care.
 5-Research
- Doing studies. Researchers might study pt
records hoping to learn how best to recognize
or treat pts with same condition.

• The aim is to promote evidenced- based

practice in nursing and quality health care.
 6-Decision Analysis
-Information from record review often provides
the data needed by strategic planners to
identify needs and means and strategies most
likely to address these needs.
• Example reviews the financial need of the
patient.
 7-Education.

• Review the patient chart can lead the

to learn about the case of the pts and about

nursing diagnosis.
8-Credentialing, Regulation, & Legislation:

--Documentation allows reviewers to monitor

health care practitioners’ and the health care
facility’s compliance with standards governing
the profession and provision of care.
 9-Legal Documentation

-The records can be also be used in evidence in

court proceeding or in accident or injury

claims made by the patient.

 10-Reimbursement.

• Patient records are also used to payers that

patients received the care for which

reimbursement is being sought.

 11-historical Document.

-The record has a value as a historical

document, years later, information concerning

a patient’s past health care might be pertinent.

Methods of Documentation:
• 1-Computerized Documentation & Electronic
Health Records: (EHRs)

• Increasingly, computer systems are used for

nursing documentation in the patient record.

In such systems the nurse may:
1-Call up the admission assessment tool on the
computer screen and key in patient data
2-Develop the plan of care using computerized
care plans available for each NANDA-
approved diagnosis or approved problem list.
3-Add to patient database as new data are
identified modify the plan of care accordingly.
4-Receive a work list showing the treatments,
procedures, & medications necessary for each
patient throughout the shift.

5-Document care immediately using the

computer terminal at the patient bedside.
 Benefits of EHRs

1-Improve quality & convenience of patient care

2-Increase patient participation in their care
3-Improve accuracy of diagnoses & health
outcomes
4-Improve care coordination.
5-Increase practice efficiencies & cost savings
6-Service elements ( such as admission and
discharge dates and expected payer for
services.)
• For safe computer charting, there are guidelines for
nurses and other health care team:
1-Never give your personal password or computer
signature to anyone
2-Don’t leave computer terminal unattended after you
have logged on
3-Follow the correct protocol for correcting errors
4-Never create, change, or delete part of permanent
record, type an explanation into the computer file with
the date, time, and your initials
5-Don’t leave information about a patient
displayed on a monitor where others may see
it.
6-Never use e-mail to sent protected health
information unless it has been encrypted to
protect it from unauthorized access.
7-Follow the agency’s confidentiality procedures
for documenting sensitive material, e.g.pt
with AIDS
 Personal Health Records: PHRs:

• Many people today are preparing online PHRs

to manage their health care via computer.

• These records contain: medical history,

diagnosis, medications -------etc.
 Health Information Exchange: HIE:

It allows doctors, nurses, pharmacists and other

health care team share the patient medical

information for consultation and for the benefit

of the patient
 2-Source-Oriented Records
;Traditional papers records where the EHRs are
not used,
• It is the one method in which each healthcare
group keeps data on its own separate
form .section of the record are designed for
nurses , physician , laboratory and x-ray
personnel and so on.
• The advantage of this record is that each
discipline can easily find and chart pertinent
data.

• The disadvantage is that data are fragmented,

making it difficult to track problems
chronologically with input from different
groups of professionals.
• Notes written to inform caregivers of the
progress a pt is making toward achieving
expected outcomes are called progress notes

• Progress notes written by nurses in a source-

oriented record are narrative notes and
address routine care include all notes related
to a pt
3-Problem-Oriented Medical Records (POMR)

• or problem oriented record, this organized

around a patient’s problems rather than
around sources of information.
• SOAP may use even that some believes it is
narrow recording the patient problems.
• All health professionals record information on
the same form.
• Subjective data, Objective Data, Assessment &
Plan the care.
*Variants of the SOAP is SOAPE, SOAPIE, and
SOAPIER, ( Intervention, Evaluation, Response)
• The advantage is the entire health care team

works together in identifying a master list of pt

problems and contributes collaboratively to

the plan of care.

 4- PIE, Problem, Intervention, Evaluation

• It is a unique system in that it does not

develop a separate plan of care. It is
incorporated in the progress notes.
• Pt assessment is performed and documented
using preprinted fill in the blank form at the
beginning of each shift
 5-Focus Charting:

• The purpose of this type is to bring the focus

of care back to the pt and the pt’s concerns.
• Topics that may appear in the focus column
include pt concerns and behavior, therapies
and responses.
 6-Charting by Exception: CBE

It is a shorthand documentation method that

makes use of well- defined standards of practice,
only significant findings or ( exceptions) to these
standards are documented in narrative notes

• Advantage;
• Decreased charting time and better tracking of
important pt response.
 7-Case management model.

• Managed care’s emphasis on quality, cost- effective

care delivered within a limited time frame has led to
the development of interdisciplinary documentation
tools.
• Advantages;
• It promotes collaboration and communication and
team work among caregivers.
• Makes efficient use of time
• Increase quality by focusing care on carefully
developed outcome.
• Collaborative pathways or critical pathways, or
care map are used in the case management
model.
• Variance charting. the usual format for
variance charting is the unexpected event ,
the cause of the event, actions taken in
response to the event. and discharge planning
*Formats for Nursing Documentation:
 1-Initial Nursing Assessment
;A typical electronic form used to record the

initial database obtained from nursing history

and physical assessment as quick as possible.

 2- Care Plan

The traditional plan of nursing care, nursing

diagnosis, goal and expected outcomes and

nursing interventions are written for each pt.

 3-Patient Care Summary
;The patient care summary contains an overview

of valuable patient information such as

documentation, lab , and test results, orders,

and medications.
 4-Critical/ Collaborative Pathways

• The case management plan is a detailed,

standardized plan of care that is developed for
a pt population with a designated diagnosis or
procedure.
• It includes
a-Expected outcomes
b-A list of intervention to be performed
c-The sequence and timing of those intervention
 5-Progress Notes

• The purpose of the progress notes is to inform

caregivers the progress a pt. is making toward

achieving expected outcomes,

• example of progress notes is the Narrative

nursing notes and the SOAP.

 6-Flow Sheet & Graphic Records
They are documentation tools used to record
routine aspects of nursing care such as; 24
Hours the intake and output , medication
record ,24 hours pt care records and acuity
charting forms such as observe the
consciousness of the unconscious due to
trauma or changing positions.
• Graphic Sheet , is a form used to record
specific patient variables, such as:
• Vital Signs- (RR,T, P, BP)
• Weight
• Intake & Output
• Bowel movements.
 7-Medication Record

• It includes documentation of all the

medications administered to the patient,

 8-Acuity Record

• A 24- hours reports are increasingly used in

conjunction with acuity reports, with which
nurses ranks patients as high –to- low acuity in
relations to both the patient’s condition and
need for nursing assistance or intervention
 9-Discharge & Transfer Summary.

At the time a pt is discharged from care or

transferred from one unit or institution or
agency to another, a clinical report should be
written that
• concisely summarize the reason for treatment,
significant findings, the
• procedure performed and any other things
that has been done for the pt.
 10-Home Healthcare Documentation:

• It has multiple purposes.

• And the nurse here must make
recommendation about the pt’s status.
• To determine whether the patient meets one
of the Medicare requirements:
a-The patient in homebound and still needs
skilled nursing care
b-Rehabilitation potential is good ( or the
patient is dying)
c-The patient status is not stabilized
d-The patient is making progress in expected
outcomes of care
 11- Long- Term Care Documentation:

It is specified by the Resident Assessment

Instrument (RAI) which helps staff gather
definitive information on a resident’s
strengths and needs and addresses these in an
individualized plan of care.
 Reporting Care
• To report is to give an account of something
that has been seen, heard, done, or
considered .
• Reporting is the oral, written or computer-
based communication of pt. data to others.
Methods of Reporting
 1-Change-of-Shift/ Hands- Off Reports.

It is given by a primary nurse to the nurse

replacing him or her by the charge nurse to
the nurse who assumes responsibility for
continuing care of the pt.
• This report might be given in written form or
orally in a meeting. Or it may be audio or
video taped.
 Typical Information are
1-Pt name, room number, diagnosis, attending physician .
2-Health status and pt’s response to medical therapy
3-Current orders( nurse’s or doctor’s orders)
4-Summary of all newly admitted pt, including his or her
medical diagnosis, age, plan of therapy and general
condition.
5-Abnormal occurrences during your shift
6-Patient/ family questions, responses, concerns, needs
7-Reports on patients who have been transferred or
discharge
 2-Telephone /Telemedicine Reports
• Or telemedicine reports, the equipment can
link healthcare professionals immediately and
enable nurses to receive and give critical
information about patients in a timely fashion.
• e.g. lab tests, any emergency in pt's status.
• When such thing is happen the nurse should
be prepared to do the followings:
a-Identify themselves and the pts
b-Report concisely and accurately the changes
c-Report the current V/S and clinical
manifestations
d-Have the pt record at hand
e-Document the date and time of the call.
 3-Transfer & Discharge Reports

• The nurse make a summary about the pt

condition and care when transferring pt from
a unit or institution or agency to another and
when discharging pt to home.
 4-Reports to family members & Significant others

Nurses play a crucial role in keeping the pt's

family and significant others updated about
the pt's condition and progress toward goal
achievement.
 5-Incident Report
• Also called a variance report or occurrence report.
• Is the tool used by healthcare agencies to document the
occurrence of anything out of the ordinary that results
in, or has the potential to result in harm to a patient ,
employee or visitors.
• These reports must be used for quality improvement
and not for punishing the staff.
• Incident reports improve the management and
treatment of pts by identifying high risk patterns and
initiating in-service programs to prevent future
problems.
 Conferring about Care

To confer is to consult with someone to

exchange ideas or to seek information,
advice or instructions.
a nurse can consult with another nurse in
different specialty for more information.
 1-Consultation & Referrals

When the nurse detect problems they cannot resolve

because they lie outside the scope of independent
nursing practice or their expertise.
• Consultation is, the process of inviting another
professional to evaluate the pt and make
recommendation to the nurse about the pt
treatment

• Referral is the process of sending or guiding the pt

to another source for assistance is.
2-Nursing & Interdisciplinary Team Care
Conferences;
• it is a meeting of nurses to discuss some
aspect of a pt.’s care. Such meetings also are
used to instruct students and practitioners
and it may include other healthcare providers
other than nurses such as physicians and lab
technicians.
 3-Nursing Care Rounds

They are procedures in which a group of nurse

visit selected patients individually at each
patient’s bedside.
• The primary Purposes of Nursing Care Rounds are;
a- to gather information.
b-to help plan nursing care.
c- to evaluate the nursing care the patient has received.
d-and to provide the pt. with an opportunity to discuss
his or her care with those administering it.
The nurses should use language that the pt can
understand. Also nurses can make round with
physicians to share nursing's perspective with them
 Using Nursing Informatics
• ANA, defined nursing informatics as a
specialty that integrates nursing science,
computer science and information science to
manage and communicate data, information,
and knowledge in nursing practice.
• The End
• Thanks