Documenting and Reporting.ppt

11- Completeness, not all data that a nurse obtains about a client can be recorded; however, the information that is recorded needs to be complete and helpful to the client and health care professionals. Nurse’s record need to reflect the nursing process, record assessment, dependent and independent nursing interventions, client problems, client comments and responses to interventions and tests, progress toward goals. 12-Conciseness, recording need to be brief as well as complete to save time in communication. 13. Accepted Terminology, Use only commonly accepted abbreviations, symbols, and terms are specified by the agency. Many abbreviations are standard and used universally. 13- Legal Prudence, accurate, complete documentation should give legal protection to the nurse, the client’s other caregivers, the health care facility, and the client. “Complete charting for example by using the steps of the nursing process as a framework, is the best defense against malpractice.” Reporting The purpose of reporting is to communicate specific information to a person or group of people. Change-of–shift Reports, is a report given to all nurses on the next shift. Its purpose is to provide continuity of care for clients by providing the new caregivers a quick summary of client needs and details of care to be given. Telephone Reports, health professionals frequently about a client by telephone. Nurses inform primary care providers about a change in a client’s condition. - The nurse receiving a telephone report should document the date and the time, the name of the person giving the information, and the subject of the information received. - The person receiving the information should repeat it back to the sender to ensure accuracy. - When giving a telephone report to a primary care provider, begin with name and relationship to the client. For example “This is Maher Battat, RN, I’m calling about your client, Shamsa Mendes. I’m her nurse on the 7pm to 7am shift’’. - Telephone