Documentation and reporting

 Part 3

              Methods of recording

Records and report must be accurate, factual complete , current and confidential . There are many method used for recording such as______

1. Narrative charting

This is traditional method of recording nursing care is a story format that describe that client status.

2. Problem oriented charting 

This is a method of the human documentation that places emphasis on clients problems.

3. Sources oriented charting 

This is a descriptive recording done by each member of healthcare team or separate records.

4. PIE charting

SOP format is developed on medical models PIE(problem , intervention , evolution) chatting has a nursing origin.

5. Focus charting 

Focus charting is a method of identifying and organising the narrator documentation of clients concerns.

6. Charting by exception (CBE)

Patient is charting method that requires nurse to record only deviations from pre - established norms.

Flow sheets

Highlight important findings and define assessment parameters and findings.

Reference documentation:- Is related to standard of nursing practice.

Bed side accessibility :-Is related to documentation forms.

Patient have four components of problem oriented charting

Database

It contains information recording assessment. E.g. history , physical examination , nurses assessment , laboratory findings.

Problem list

Best of on the database list of problem planning (physiological , social , spiritual , cultural, environmental, etc)

Initial plan

Based upon the identified problems , care is developed with clients active participation is setting goals , outcomes and interventions.

Progress notes

Health team members will evaluate and record the progress of  client's problems information can be expressed in various formats such as SOAPIE or SOAP.

Computerized documentation

Nurse use computer to store the client database , add new data , created and revise care plans and documents client progress.

Advantages

1. Legibility of information 

2. Increased time efficiency , consistency and accuracy in records keeping .

3. Provide database for research.

4. Patient link various sources.

5. Client information , request and result are sent and received quickly.

6. Standard terminology improve communication.

Disadvantages

1. Clients may not have privacy is security measures are not used.

2. System failure can cause an availability of information.

3. System is expensive.

4. Extended training may be required whenever an updated system is installed.