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Nursing documentation is responsible for keeping the legal record of the patient, which is known as the patient’s chart, regarding his nursing documentation and reportpersonal information and care.

On the other hand, nursing reporting occurs when two medical professionals directly and indirectly involved in the care of the patient collaborate and exchange information about the care of the patient, either by personal or telephone conversation.

What are the functions of the patient’s chart?

1. Communication

It serves as a well-organized process of relaying necessary information from one care provider to another. It imparts important data about the patient’s condition.

2. Legal Documentation

It will serve as legitimate evidence used even in court.

3. Research

Health information provided which can be basis for ongoing and future research

4. Statistics

It can be used as a statistical data for health-related planning

5. Education

Health science students can utilize the facts for educational purposes

6. Review and Quality Assurance

The record can be utilized to assess the healthcare quality provided to the patient and the competency of the healthcare provider.

7. Preparation of Patient’s Care

The chart can be the source of information for the whole healthcare team to plan the patient’s care.

Good Features of Nursing Documentation and Recording

1. Concise

It is not necessary to use complete sentences in charting. For each entry, begin with a capital letter for the first letter of the initial word and end the statement with a period.

2. Permanence or Proper Usage of Ink

Use ball pen when writing any information on the chart. Avoid using felt pen or pencil.

3. Accurateness

State only the facts regarding the care. The healthcare provider’s opinions or interpretations are not necessarily included.

Example:

Correct: Consumed 2 Liters of water.
Incorrect: Drank plenty of water.

Additionally, use proper punctuation marks to quote the patient’s statement.

Example:

“I feel a stabbing pain on the center of my chest.”

It is important to include the objective data.

Example:

Temp.=38.1ْ˚,PR=101bpm,RR=28bpm,BP=140/80mmHg,diaphoretic,skin warm to touch.

Behaviors are noted instead of the patient’s feelings.

4. Appropriateness

The important and relevant information are the only ones noted in the chart.

5. Comprehensiveness and Correct Order

Charting entries should be uninterrupted and are only allowed to continue on another line if the entry is done on another time. Double charting is prohibited. Inserting additional data in between spaces is also not allowed. Further information is entered on the first available line.

6. Usage of Standard Terminologies

AbbreviationLatinEnglish
a.c.ante cebumBefore meals
ad.lib.ad libitumAs desired
ADLActivities of daily living
ax.Axillary
bidbis in dieTwice a day
BMRBasal metabolic rate
BPBlood pressure
c.c.cumWith
capcapsulaCapsule
gttguttaDrop
h.s.hora omniHours of sleep
IMIntramuscular
IVIntravenous
mcgttMicrodrop
  • od
  • omni die
Once a day
OD
  • oculus dexter
Right eye
  • o.m.
  • omni mane
Every morning
OS
  • oculus sinister
left eye
OU
  • oculus uterque
Both eyes
p.c.post cebumAfter meals
p.o.per oremBy mouth
p.r.n.pro re nataAs necessary
q.h.quaque horaEvery hour
q.i.d.quarter in dieFour times a day
s.s.sineWithout
s.c.sub cutemSubcutaneously
ss.semisOne-half
statstatimImmediately
tidter in dieThree times a day

7. Properly Signed

Place the full name and status of the healthcare provider with signature affixed on top of the name.

Example:

(Signature)

_____________________________Charity F. Marquez, R.N.

8. Avoid Errors

In case of an error, place a horizontal line over the wrong data. After which, place the word “error” on top of the mistake and affix the healthcare provider’s signature.

Example:

ERROR CM

BP=120/90mmHg  BP=130/90mmHg

9. Legible Handwriting

Handwritings should be readable and clear for others to see.

10.Do not Leave Spaces

Place horizontal lines on spaces to avoid others from inserting additional data on the nurse’s notes.

11. Confidentiality

All information stated in the chart should be kept private.

Kinds of Nurse Records

Traditional Patient Record

The different individuals or departments involved in the patient’s care have allocated sections in the chart.

Parts:

  1. Admission Sheet
  2. Doctor’s Order Sheet
  3. Medical History
  4. Nurse’s Notes
  5. Other important reports and records ( laboratory findings, vital signs sheet, input and output sheet, referrals)

Problem Related Patient Record

The patient’s information are documented and organized in accordance to the origin of the data. The chart incorporates all the information regarding the problem as identified by the healthcare team.

Elements:

  1. Database
  2. List of Problems
  3. Preliminary Plan of Care
  4. Progress Notes

Nurse’s notes (SOAPIE of FDAR format)

  1. Flow Sheets
  2. Discharge Notes and Referral Summary

Kardex

It is an organized and concise sheet regarding the patient’s information and care used during endorsements. It is available to all the healthcare providers involved in the patient’s care.

Components:

  • Demographic or personal information
  • Basic needs
  • Allergies
  • Laboratory tests
  • Daily nursing procedures
  • Medications, intravenous fluids and blood transfusions
  • Other treatments like suctioning, mechanical ventilation, oxygen therapy or dressing change

Kinds of Nursing Reporting

End of Shift Reporting or Endorsement

It is mainly done for continuity of care. Aside from the information stated in the Kardex, other important data regarding the patient’s care is also endorsed to the receiving team.

Telephone Reports

Telephone reports are usually brief and clear. These information should be included:

  1. Date and time call was made
  2. The name of the person who made the call
  3. The receiver of the call
  4. The receiver of the information
  5. The data given
  6. The data received
  7. Telephone Order

Registered nurses are the only ones who can receive and process telephone orders. Telephone orders are validated by relaying the information clearly and accurately. This kind of order should be countersigned by the doctor who gave the order in no more than 24 hours.

Transfer Report

This type of reporting is done when a patient is transferred from one department to another.

Reference:
Quiambao-Udan,J.(2004). Mastering Fundamentals of Nursing. (2nd Ed.). Educational Publishing House.

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Being a nurse-writer reflects both my profession and passion for my calling. I believe writing is the greatest way for me to promulgate the insights that I'm best with. Medical-Surgical Nursing and Anatomy & Physiology are my two strongest specializations in the field.