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06/11/1431
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Ra'eda AL-Mashaqba 1
DOCUMENTING AND
REPORTING
Chapter 20
Ra'eda AL-Mashaqba 2
Purpose of clinical recording
Communication :prevent fragmentation ,repetition
and delays in client care.
Planning care plan
Auditing :review of record for quality assurance
Research
Education
Reimbursement
Legal documentation
Health care analyses : identify health care need
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Ra'eda AL-Mashaqba 3
Documenting nursing activates
Admission nursing assessment .
Nursing care plans
Kardex (written pencil)
Flow sheets:
Graphic clinical record
Fluid balance record
Medication record
Progress note
Nursing discharge record
Ra'eda AL-Mashaqba 4
Guide line for recording
Date and time : document the date and time of each recording .
Timing: documentation should be done as soon as possible after an assessment or intervention ,no recording should be done before providing nursing care.
Legibility: must be legible and easy to read to prevent interpretation error.
Permanence : all entries on the client record are made in dark ink.
Accepted terminology: use only commonly accepted ,symbols ,and term that are specific by the agency.
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Ra'eda AL-Mashaqba 5
Correct spelling.
Signature each recording on the nursing note
is signed by the nurse making.
Accuracy :
The client name and identifying information should
written on each page of the clinical record.
Notation on record must be accurate and correct.
Accurate notation consist of facts and observation
rather than opinion or interpretation.
Avoid general word such as large, good, or
normal.
Write in every line but never between line.
Ra'eda AL-Mashaqba 6
Sequence.
Appropriateness: record only information that
parties to the clinical health problem and care
and not personal information.
Completeness.
Conciseness: recording need to be brief as
well as complete.
Legal prudence: accurate, complete
documentation should give legal protection to
the nurse.
