Transcript Documenting and reporting

Documenting and reporting
Pages 104-111
Prepared by: Dr.Reem A.Jarrad
Why communication between staff
is important?
Because it enhances quality and
continuity of clients care
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Definitions of nursing communication
methods
1- Discussion: is an informal oral
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consideration of a subject by two or
more health professionals to
identify a problem or to develop
strategies to resolve one.
Definitions of nursing communication
methods
2- Report: is oral, written or
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computer based communication
intended to convey information to
others.
Definitions of nursing communication
methods
3- record : is a written or computer
based documentation( charting or
recording).
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What are the purposes for using client
records?
1- Communication
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2- Planning client care
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3- Auditing health agencies ( quality assurance)
4- Research
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5- Education
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6- Legal documentation
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7-Health care analysis ( SWOT= strengths,
weaknesses , opportunities, and threats)
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Documentation Systems
1- Source oriented record
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2- Problem oriented medical record
3- Pie ( problems, interventions and
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evaluation)
4- Focus Charting
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5- Computerized documentation
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Note : practice tips for documentation on the bottom of
page 108).
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General Guidelines for recording
1- Date and time
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2- Frequency of documenting according to policy and
client condition
3- Legibility ( easy to read..)
4- Permanence ( dark ink)
5- Accepted Terminology
6- Correct spelling
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General Guidelines for recording
7- Signature
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8- Accuracy ( how to manage wrong entry?)
9- Sequence (order of occurrence)
10- Appropriateness (
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relevant client data only) 
11-Conciseness ( Brief recording)
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12- Legal caution( look nursing note page 107, right
upper border, directly above word reporting)
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Reporting
Definition:
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to communicate specific information
to a person or group of people,
whether oral or written.
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Examples for Reporting
1- Change of Shift Reports
2- Telephone reports
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3- Care Plan Conference
4- Nursing Rounds
(Pages 107-108)
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Good luck with first exam
- Which will be on the 28-10-2014
The same time and place of the 
lecture.
- Two value- ethics lectures will 
remain after the exam, and will be
included in the second exam
Your Tutor
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