Documenting and reporting Pages 104 111 Prepared by
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 ¡
Definitions of nursing communication methods 1 - Discussion: is an informal oral ¡ 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 ¡ 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). ¡
What are the purposes for using client records? 1 - Communication ¡ 2 - Planning client care ¡ 3 - Auditing health agencies ( quality assurance) 4 - Research 5 - Education ¡ ¡ 6 - Legal documentation ¡ 7 -Health care analysis ( SWOT= strengths, weaknesses , opportunities, and threats) ¡ ¡
Documentation Systems 1 - Source oriented record ¡ 2 - Problem oriented medical record 3 - Pie ( problems, interventions and ¡ ¡ evaluation) 4 - Focus Charting ¡ 5 - Computerized documentation ¡ Note : practice tips for documentation on the bottom of page 108). ¡
General Guidelines for recording 1 - Date and time ¡ 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 ¡ ¡ ¡
General Guidelines for recording 7 - Signature ¡ 8 - Accuracy ( how to manage wrong entry? ) 9 - Sequence (order of occurrence) 10 - Appropriateness ( ¡ ¡ relevant client data only) ¡ 11 -Conciseness ( Brief recording) ¡ 12 - Legal caution( look nursing note page 107, right upper border, directly above word reporting) ¡
Reporting Definition: ¡ to communicate specific information to a person or group of people, whether oral or written. ¡
Examples for Reporting 1 - Change of Shift Reports 2 - Telephone reports ¡ 3 - Care Plan Conference 4 - Nursing Rounds (Pages 107 -108) ¡ ¡
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 ¡
- Slides: 12