Documentation and reporting

 Part 1

                                 Unit - 6

DOCUMENTATION and REPORTING

Documentation is any written electric electronically generated information about a client that describe the care or service provided to that clients .

It may be record in the form of paper documents or electronic medical records , faxes, emails, audio or video tapes and images.

By the process of documentation a nurse can communicate easily with other health team members and clients and understand their problems or need.

Nursing documentation clearly described

An assessment of the client health status nursing intervention carried out the impact of thus intervention on clients outcomes.

A care plan or health plan reflecting the needs and goals of the clients.

Information reported to a physician or other health team member.

Advocacy undertaken by the nurse on behalf of the client.

Record

It is defined as a clinical , scientific, administrative and permanent legal documentation of information related to the clients healthcare.

Purpose of recording

Communication :- with the help of the record health team member can communicate easily regarding to the status of the  patients.

Quality of care:- record help to identify the health needs of the patient , various interventions carried out on patient and their outcomes.

Legal documentation:- legal documentation help in legal worked . It helps police and health care team during accident or any criminal work .

Planning patient care:- review of patient record is done to assess the health condition of the clients  and to plan further care.

Audit :- An audit is done to assess the standard and quality of care provided in institution by reviewing the patients records.

Research :- the information in a patient records can be used as a source for nursing and health research projects.

Importance of records

For family and individual

Record serve as a detailed description of client history .

 Assist in continuity of care.

 Evidence to support legal issues.

For Physician

Serve of guide for diagnosis and treatment.

 Self evolution of medical practice .

Teaching and research.

For Nurses

Document nursing service in hospital .

Guide for professional growth.

 Act as  communication tool.

For Authority

Record provide satisfied information .

 Provide future it reference. 

Evaluation of care in terms of quality and adequacy.