Chapter 20 DOCUMENTATION AND REPORTING SKILLS
Verbal reporting and documentation are two ways in which communication takes place among members of the health care team. Both are an account of what has been assessed or observed about a client and the care that has been implemented. Health care team members rely on reports and records to deliver care that is directed towards mutually agreed goals. Continuity of care and the pursuit of common objectives depend upon effective communication between members of the health care team, which involves accurate and precise verbal and written reporting and recording of information.
After working in acute care for so long I was overwhelmed with the amount of paperwork involved with aged care. It took a while to get my head around all the jargon but I now understand why it is all so important.
Documentation of nursing interventions and management associated with client health status serves two broad purposes: it is a means by which members of the health care team can provide appropriate care for the client, while also becoming a historical outline of the client’s care for future reference if needed; and it is a contemporaneous record of events that have taken place and is therefore most likely an accurate record of those events (Crisp & Taylor 2005).
Both these purposes have legal implications for all concerned. As a means of client care, clinical records can be used in court either to prove or to refute a claim of negligence on the part of a health professional. Given the contemporaneous nature of a client’s clinical records, the courts may use them to determine what care was or was not given, and the condition of the client at any particular time. Nurses therefore need to be mindful of these potential legal uses and develop their writing skills accordingly.
In addition, nurses need to meet professional and ethical responsibilities to maintain accurate records in relation to the treatment and care given to clients. For nurses, sound documenting skills are unquestionably good nursing practice and essential in facilitating effective nursing care.
The purpose of documentation is to facilitate optimal client outcome through communicating accurate, objective and contemporaneous descriptions of clients’ health status and ongoing care. Documentation completed through professional and accurate writing, with legislative and ethical requirements in mind, helps to ensure that continuity of client care is provided. All clients require documentation, which includes records of assessment, diagnosis, planned interventions and subsequent care evaluations (Crisp & Taylor 2005).
Records, which promote continuity of care, are the means by which various members of the health care team communicate information about the client’s condition and the type of care that has been implemented. Written records (progress notes) provide permanent and accurate assessment of clients, their health status and progress, and the data necessary to plan and implement care. As part of quality assurance programs, health care agencies perform audits in which the information contained in client records is reviewed on a regular basis. Audits are performed to determine the degree to which specified quality assurance standards have been met (Berglund & Saltman 2002).
Written records provide a great deal of information, for example, about nursing diagnoses and evaluation of care that has been implemented, which may be used for educational purposes. The information contained in records may also serve as a source of data for research. Records also become a legal document, for example, if a client takes legal action against a health care agency, client records can be used as evidence in courts of law, where they are read and interpreted by lawyers. In addition, some records are now accessible by clients under the Freedom of Information Act (1982). Written records assist to ensure the continuity of client care through professional, accurate and contemporary documentation.
The two most commonly used record formats are the traditional source records and the problem-oriented records. In the source method, information is grouped according to its source; for example, the record is divided into the nurse’s notes, the medical officer’s record, laboratory reports and the physiotherapist’s report. Using this method each member of the health care team uses a separate section of the record to record data. While this method of recording enables each category of health care team member to make detailed entries, it does lead to the fragmentation of data, as the information is not written according to the client’s identified problems.
The problem-oriented method groups information from all members of the health care team into sections according to a client’s specific health problems, whereby each member of the team contributes to a single list of identified client problems. When this system is used it is easy to recognise and locate the client’s health care problems on a single record. While each health care agency adopts its own record format, many use a problem-oriented system of total client recording that includes all the information relevant to a client’s care (Berglund & Saltman 2002).
Documentation must always be completed in a professional, accurate and objective manner. Factors that are to be considered when completing documentation in relation to care or treatment provided to a client include:
In major health care agencies computers are used to record client information. With computerised systems recording significant amounts of client information it is important for nurses to become familiar with any such systems being used in their workplace. An issue of concern in the use of computer technology is the potential threat to the privacy of the client. Policies and procedures in relation to client health information need to be in place and adhered to by nurses to protect individual rights to privacy and confidentiality. Further information on computers in nursing is covered in Chapter 25.