Documentation system
Application for Models for Organization and
Guidelines for Contents
 1- Source oriented record: the information about a patient's
care and illness is organized according to the "source" of the
information within the record, f it is recorded by the physician, the
nurse, or data collected from an x ray or laboratory test are filed under
their specific sectionalized areas in the chart usually in chronological
order. Many facilities use this format since it is easy to locate
documents.
 For example, if a physician needs to reference a
recent lab report, it can easily be found in the
laboratory section of the record. However, if a
physician wanted to reference all information about a
particular diagnosis being treated or treatment given
on a particular day, many sections of the record
would have to be referenced making it difficult to
amass all the information for that specific diagnosis
difficult.
 Each person or department make notations
in a separate section or section of the client
chart.
 Narrative charting is a traditional part of the
source oriented record .
Advantages
Disadvantages
Convenient and easy to trace .
The information about the a
particular client problem is
scattered throughout the client
chart.
Cont’
 2- problem oriented medical record :
 The data arranged according to the problem the client
has rather than the source of the information. we will define
problem as anything that interferes with the health, well being and
quality of life of an individual, that may be medical, surgical,
obstetric, social or psychiatric,
 The health team contribute to the problem list , plan of
care and progress note .
Cont’
Advantages
Disadvantages
a) Encourages collaboration
a) Caregivers differ in their ability
to use the required charting format
.
b) The problem list in front of the
chart alert the caregivers to the
client needs and makes it easer to
track the status of each problem .
b) It tack constant vigilance to
maintain an up-to- date problem
list.
c) It is somewhat inefficient .
Cont’
 The problem oriented medical record has 4 basic
component : (POR) has four parts:
1- Database . Is an overview of patient information
2- problem list .
The problem list is the first document encountered in the patient's char
t. It serves as a guide to the current and important
health problems of the patient.
3- plan of care . which specifies what is to be done with regard to each
problem
4- progress note .
which document the observations, assessments, nursing care plans, phy
sician's orders, etc., of allhealth care personnel directly involved in the c
are of the patient. .
Cont’
 3- The Integrated Health Record Format :
 Integrated health record format organizes all the paper forms in
strict chronological order and mixes the forms created by different
departments.
TYPES OF RECORDS 
1. Patients clinical record 
2. Individual staff records 
3. Ward records 
4. .Administrative records with educational value 
PATIENTS CLINICAL RECORDS It is the knowledge of 
events in the patient illness, progress in his or her recovery
and the type of care given by the hospital personnel.
INDIVIDUAL STAFF RECORDS. • A separate set of 
record is needed for staff, giving details of their sickness and
absences, their carrier and development activities and a
personnel note
WARD RECORDS. • Reducting or increase in beds. • . 
Change in medical staff and non nursing personnel for the
ward. •
ADMINISTRATIVE RECORDS WITH EDUCATIONAL 
VALUE. • • • • • Treatments. Equipments losses and
replacements. Personnel performance. Other administrative
. records
Reporting
 DEFINITION Reports are oral or written exchanges of information
shared between care givers of workers in a number of ways. A report
summarises the service of the personnel and of the agency
 CRITERIA FOR A GOOD REPORT • made promptly. • clear,
concise, and complete. • If it is written all pertinent, identifying data
are included-the date and time, the people concerned, the situation, the
signature of the person making the report. • It is clearly stated and well
organized • Important points are emphasized. • In case of oral reports
they are clearly expressed and presented in an interesting manner.
 The purpose of reporting is:
 to communicate specific information to a person
or group of people . (an essential tool to communication )
 • To show the kind and amount of services rendered over a




specific period.
• To illustrate progress in teaching goals.
• As an aid in studying health condition.
• As an aid in planning.
• To interpret the services to the public and to the other
interested agencies.
REPORTS IN NURSING EDUCATION 
• Factual data related to the students, staff, clinical 
facilities, physical facilities, administration and the
curriculum
• Development made in the school programme since 
the last report.
• Proposal and plans for future development. 
• Problems encountered 
• Recommendations 
TYPES OF REPORTS 
1. 24 hours reports 
2. Census report 
3. Anecdotal report 
4. Birth and death report 
5. Incidental report 
CLASIFICATION OF REPORTS BASED ON TYPES 
• Oral reports 
• Written reports 
REPORTS USED IN HOSPITAL SETTING:• • • 
• CHANGE – OF – SHIFT REPORTS TRANSFER 
REPORTS
INCIDENT REPORTS
LEGAL REPORTS 
 Types of report :
 1- Change – of- shift report :
 is report given to all the
nurses next shift .
 It is purpose is to provide
continuity of care for client.
Cont’
 2- Telephone Report :
 The nurse receiving a telephone report should document
Ex:
 6/6/03 10:35 AM Omar Ahmad , laboratory
technician , reported by telephone that Mrs. Sara
Mohammed hematocrit was 39/100ml ____
B.Irland RN.
Cont’
 When giving telephone report to a physician telephone
report include
Ex:
 Dorothy Mendes admitted 12 noon; c/o burning upper
right quadrant abdominal pain, BP 120/80 , p 100, R 20 ,
on admission. Demerol 100 mg IM on admission , At 3:15
pm BP 100/40,P 120 , R 30. Pain unchanged. Color pale
and diaphoretic . Reported by telephone to Dr. Burns at
2:10 pm ___ TS Jones RN.
Cont’
 3- Telephone Order :
 While the physician gives the order write it down and
repeated back to the physician .
 Ask the physician about any order that ambiguous, unusual
, or contraindicated by the client’s condition.
 Transcript the order to the physician order sheet.
 The order must be countersigned
by the physician within a time
period described by agency policy .
Cont’
 3- Care plan conference :
 Is a meeting of a group of nurses to discuss possible
solution to certain problem of the client . It is allow the
nurses an opportunity to offer an opinion about possible
solutions to the problem.
 4- Nursing Round :
 procedure in which tow or more nurses visit selected
client at each client bed side to :
 a) Obtain information that will help plan nursing care.
 b) provide the client the opportunity to discuss their care .
 C) Evaluate the nursing care the client has received .
ADVANTAGES AND DISADVANTAGES OF REPORTS 
ADVANTAGES • • • • • 
Monitoring operations 
Controlling 
Guide decision 
Employee motivation 
Performance evaluation 
DISADVANTAGES • It is time consuming. • Expensive • 
Reports can be biased • Sometimes implementations of the
recommendations of a report become unrealistic. • Technical
reports are not easily understandable
NURSES RESPONSIBILITY FOR RECORD 
KEEPING AND REPORTING • • • • • • Records and
reports must be functional accurate, complete,
current organized and confidential FACTS
ACCURACY COMPLETENESS CURRENTNESS
ORGANIZATION CONFIDENTIALITY
.39 
COMMON PROBLEMS THAT OCCUR DURING 
REPORT WRITING.
CONTENT AND ORGANIZATION • Problem - No section 
headings • Problem - missing items related to the format •
Problem - lack of numbering
Common problems that occur during report .40 
writing.(Contnd..)
GRAMMAR, VOCABULARY, SENTENCE AND TONE. 
OTHER PROBLEMS • Incomplete sentences • Confusing
and unclear sentences. • Miscommunication • Too general •
.Confidentiality. • Missing information and facts. • Wordiness
Basic essential reports 
Documenting Nursing activities
 1- Admission Nursing Assessment :
Cont’
 2- Nursing care plans :
2 type
Traditional
Written for
each client
Standardized
Developed to save
documentation time
3- Kardexes:
4- Flow sheet :
5- Progress note :
 Provide information about the progress a client is making
toward achieving desired outcomes .
6-Nursing Discharge / referral Summaries
 Completed when the client being discharged or
transferred to another institution or to home where a visit
by community health nurse .
 If the client transferred within a facility or from long term
facility to a hospital, a report needs to accompany the
client to ensure continuity of care in the new area .
 It is include some or all of the following :
 1- Description of the client status.
 2- Resolved health problem .
 3- unresolved health problem
and continued care needs
Cont’
 4- Treatment that are to be continued .
 5- Current medication .
 6- restriction that are relates to activities, diet, bath.
 7- functional / self care abilities.
 8- comfortable level .
 9- Support network .
 10- client education .
 11- Discharge distention.
 12- Referral services.
Thank you for your
listening