recording - ncm 100

7/30/2019 Recording - Ncm 100

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RECORDING /REPORTING


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Recording Records are written accounts of patients observation and

therapy. are written, formal, legal documentation of the

clients progress.

Patients Record/chart/hospital chart- Is a legal document which provides evidence of

the care given to a patient in a particular agency.- Is a communication linkage or system by

which members of the health team exchange

views and information about the patient and histherapy.


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Purposes of Client

Record Planning clientcare

Communication Legal

documentation

Research

Education

Nursing audit

Statistics Accrediting and

licensing

Reimbursement


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Contents of the Patients

Chart1. Face sheet2. Admission Form

3. Medical History

4. Nursing History

5. Graphic Sheet

6. Activity Flow Chart

7. Medication Sheet /Record

8. Doctors order sheet

9. Nurses notes

10. Progress notes

11. Laboratory sheet

12. Problem list

13. Health team notes

14. Discharge plan


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Nurses Notes / charting

is the method used to document, using thenursing process, which includes theobservations that the nurse made about

the patients condition, the statement ofthe problem, the care, and the treatmentthat was delivered and the patientsresponse.


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Guidelines for determining

when charting is required:1. Chart anytime the patients condition warrants

it.

2. Admission date must be recorded as soon aspossible after the patient is admitted.3. Record medication administration as soon as

possible.4. If the patient leaves the nursing unit, make a

notation in the chart before the patient leavesand upon the patients return.5. Chart relevant observation


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6. Record any unusual or untoward incident, thetime, the result of nursing actions and the

patients response promptly and completely.7. Document anytime when the nurse gives care,

treatments, or makes an assessment of thepatient.

8. Visits by members of the health team.

9. The therapeutic measures ordered by thephysician.

10. Specific measures the physician carries out onher own.

11. Evaluation of the effectiveness of nursinginterventions measures both dependent andindependent.


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Guidelines for Recording Writing must be legible On every notation, document the date and time

of the recording and of the assessment orintervention. No recording should be donebefore providing nursing care.

Clients record is restricted to members of thehealth team included on the care of the patient.

All entries on the clients record are made indark colored ink.

Sign each recording and include first and lastname and the title of the person making thenotation.

Accurate notations consist of facts or exactobservations rather than opinions orinterpretations of an observation.


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When describing something, nurses shouldavoid general words such as large, good andnormal.

Correct spelling is essential for accuracy inrecording Errors should not be erased or blotted out. Document events chronologically, what

happens first, next and last.

Only information that pertains to the clientshealth problems and care is recorded. Use only commonly accepted abbreviations,

symbols, and terms that are specified by theagency.

Recordings need to be brief as well ascomplete. Do not leave space between entry. Legal awareness


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Two General Forms of

Records1. Source Oriented / Traditional

Record.2. Problem Oriented / Medical

Record


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1. Source Oriented

Record- Is the information about thepatients care that is narrative form

and is usually charted in chronologicalorder regardless of the topic underconsideration.

- Information is organized accordingto the source of that information.


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2. Problem Oriented

Record (POR)- Is organized according to the

identified problem of the patient.

- All members of the health care teamwrite proper notes about the sameproblem on the same problem on thesame form in the chart.


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Components of POR

1. Baseline Data consist of all the informationabout a patient obtained during admission.

2. Problem List is a series in chronological orderof identified patient problem or diagnosis

- result of manipulation andinterpretation of new information collected inthe database.

3. Initial plan of Care completed as soon aspossible after admission and is the beginning

looking plan of the team.4. Progress notes


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Kinds of Progress Notes

1. Narrative Charting records patient progress ina day to day basis.2. SOAP / SOAPIER format3. PIE charting4. Flow Sheets is designed to facilitate the

recording of recurring treatment or observationin a graphic form.5. Discharge Notes a description of problem

identified, and the degree to which eachproblem has been resolved, accomplished during

the patients discharge6. Discharging a client Against Medical Authority


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Other Written Documentation

Kardex it is a summary of thepatients problem and therapy and is

readily accessible to all members ofhealth team as well as being usedduring changes of shift.

recording - ncm 100

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