Chapter 9
Recording and Reporting
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Medical Records
 Recording referred to (process of writing information)
 Other words (Reporting, Documenting, Charting, and Recording) .
 Medical (health) records are written collections of
information about a person’s health, the care provided
by health practitioners, and the client’s progress
 Also known as health records or client records
(files)
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Uses of Medical Records
1. Permanent account

The record is filled and maintained for future references.
2. Sharing information


Continuing of care.
Prevent duplication or omission
3. Quality assurance


Continues quality improvement.
To improve the quality of care.
Accreditation (Official Approval)
4.
5. Reimbursement (To pay the coasts of documented care).
6. Education and research
7. Legal evidence
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Components of Medical Records
1. Person’s health information
2. Care provided by health practitioners
3. The client’s progress
4. The plan for care
5. Medication cycle
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Types of patient's records
1. Source-Oriented Records
 Organized according to source of documented
information
 Contain separate forms for physicians, nurses,
dietitians, physical therapists to make written entries
about their specific activities in relation to client’s care
 This record provides fragmented documentation
 Consider of traditional type of record
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2. Problem-Oriented Records
 Organized according to client’s health problems
 Four major components: data base, problem list, plan of
care, progress notes
 Information arranged to emphasize goal-directed care;
promote recording of pertinent information; facilitate
communication among health care professionals
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Components of
Problem-Oriented Records
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Methods of Charting
1. Narrative charting


Style of documentation generally used in Source-Oriented Records.
Involve writing information about the patient and patient's care in a
chronologic order.
2. SOAP charting


Style of documentation more likely to be used in a Problem-Oriented
Record.

S = Subjective Data.

O = Objective Data..

A = Analysis of the Data..

P = Plan for care.
Some agencies have expanded the SOAP format to SOAPIE or SOAPIER

I = Interventions

E = Evaluation

R = Revision to the plan of care
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Methods of Charting (cont’d)
3. Focus charting (DAR model is used )

D = Data
A = Action
R = Response
4. PIE charting

P=Problem
I=Intervention
E=Evaluation
5. Charting by exception

Method in which only abnormal assessment finding are written.
6. Computerized method

Documenting patient information electronically
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DOCUMENTING INFORMATION
 Abbreviations
 Abbreviations shorten length of documentation and
documentation time
 Agencies provide list of approved abbreviations and
their meanings
 Use only abbreviations on agency’s approved list
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DOCUMENTING INFORMATION (cont’d)
 Documentation Time
1. Traditional time
– Two 12-hour revolutions; identified with hour and
minute, followed by a.m. or p.m.
2. Military time
– Based on 24-hour clock; uses different four-digit
number for each hour and minute of the day
o
First two digits indicate hour within 24-hour period
o
Last two digits indicate minutes
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Documentation Time (cont’d)
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Charting Guidelines
 Should not be time-consuming to write and read
 Everyone involved in the care of a client should make
entries in the same location in the chart
 The nurse should address specific content in charted
progress notes
 Assessments should be documented on a separate form
 Information should always be clear
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Charting Guidelines (cont’d)
 Abnormal assessment findings, or care that deviates
from the standard, should also be documented separately
 Client information should be documented electronically
 Abbreviations and terms should be consistent with
agency-approved lists
 The date of the documentation should be recorded
 The time of the documentation should be recorded
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Written Forms of Communication
1) Nursing care plan: list of client’s problems, goals, and
nursing orders for client care
2) Nursing Kardex: quick reference for current
information about client and client care
3) Checklists: documentation with check mark or initials
4) Flow sheets: documentation with sections for
recording frequently repeated assessment data
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Other Forms of Communication
1. Change of shift reports: Discussion between a nursing
spokes person from the shift that is ending and personnel
coming duty.
2. Client assignments: Are made at the beginning of each
shift.
3. Team conferences : Are commonly used for exchanging
information
4. Rounds : Visit to patients on an individual basis or as
group
5. Telephone calls
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Nursing Documentation
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