Reporting and Documentation

Nurses must communicate information about the patient accurately, completely, and in
most timely and effective way possible. Standards of Nursing Practice require that
documentation be pertinent, concise, and reflective of the patient’s status. Nursing interventions
and patients responses must be documented.

Guidelines for Good Reporting and Documentation

1. Factual – information about the patients and their care must be based on facts that are
descriptive and objective.

2. Accurate – a client’s record must be accurate and reliable.

Example:
7:00 AM - D5LRS – I liter started as IV on left cephalic vein at 30 gtts/min.
Infusing well.
3:00 PM - Consumed. Ffd by another liter of same sol. As ordered. Infusing well.
- Claims to feel better.
- Urine output – 250 cc.
N.V. Manalastas BSN, R.N.
Nurse II

3. Confidential – the information given by patients and their families are privileged. Information
gathered by examination, observation, conversation or treatment should be shared only with the
members of the health team participating in the patient’s care or when the patient himself/herself
has permitted the release of information.

4. Complete – charting should be complete and concise giving only essentials information.

5. Current – recording and reporting should be up-to-date. Includes vital signs, treatments,
diagnostics, admissions, discharges, death etc.

6. Organized – the information should be communicated in a logical format or sequence.

7. Ethical – negative or retaliatory remarks about a patient or member of the health team should
be avoided as these breed ill-feeling and poor relationships.
Example:
“Refused oral medications. Spat these out.”

Precautions to Observe in Documentation

1. Only the nurse who performs the nursing intervention makes the entry and signs it.
2. Charting made by nursing students should be countersigned by their clinical instructor.
3. Chart all important information before going on a break or when leaving the unit.
4. Do not make erasures.

Reports
Reports are either oral, taped or written exchange of information between nurses and/or
members of the health team.
1. Change-of-Shift Reports
A change-of-shift report is a system of communication aimed at transferring essential
information and holistic care for patients.
a. Oral Report – any information that may alarm the patient and/or his/her family is
reported out of hearing.
b. An audio-tape report – this is made by outgoing nurse and is replayed by the
incoming nurse.
c. Nursing Rounds – are made at the patient’s bedside. The patient’s care plan is
discussed.

2. Telephone Reports and Orders

These are occasions when nurses give telephone reports to physicians about changes in
the patient’s conditions or to another nurse in another unit about a transferred patient. The nurse
should note the date and time when the order was made, when he/she wrote the order, the name
of the physician, then his/her sign including designation.
Example:
2-25-01 = Discontinue IV infusion when consumed
3:20 PM
Tel. Order Dr. J.V. Santos

P.F. Roxas BSN, RN.

Staff Nurse

3. Transfer Reports
A patient may be transferred to another agency after proper referral and coordination. The
transfer report accompanies the patient. It contains information that the nurse in the receiving
unit needs to know for continuity of care.

Documentation
Documentation is anything printed or written that can be used as record or proof for
authorization. A medical record is a comprehensive description of the client’s health status and
needs as well as evidence of each health care member’s accountability in giving that care.

Purpose of Records
1. Communication – it keeps track of the patient’s progress and condition and the measures taken
to maintain continuity of care.

2. Legal evidence of care – the record serves as a description of what happened to the patient.

3. Education – a client’s record is used by students of medicine, nursing and other paramedical
students for educational purposes.

4. Financial Billing – a review of patient’s record determines the payment or reimbursement that
a client will pay or receive.
5. Evaluation of quality care rendered – this is done to determine the degree to which quality
assurances or quality improvement standards are being met.

6. Research and Statistical Information – used to describe characteristics of client population in a

healthy care agency as well as clinical records.