Chapter 20 DOCUMENTATION AND REPORTING SKILLS
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).
DOCUMENTATION GUIDELINES AND PRINCIPLES
• Entries should be contemporaneous (as it happens) with the event and recorded in chronological order
• Even routine observations and assessments of changes of a client’s condition must be recorded; if no entry has been made it may be inferred that no observation or subsequent care was provided
• The client’s full name, hospital number and other pertinent details are clearly stated on each sheet
• Any errors made are not erased or scratched out. Instead, the nurse should draw a single line through the error, write the word ‘error’ and initial it or sign their name. Under no circumstances should any form of white out (e.g. Liquid Paper, Tippex) be used when documenting in progress notes or assessment entries.
• No lines or spaces are left. A line should be drawn through the blank space in a partially completed line of writing to prevent others from recording in a space with someone else’s signature
• Nursing actions are not recorded before they have been performed. Once performed they are recorded immediately to avoid errors or omissions
• Recording is performed in a logical and sequential manner. An organised record, for example progress notes, addresses each topic thoroughly before a new topic is introduced
• The information is accurate, concise and factual. Objectivity of entries is maintained by reflecting on what has actually been seen, heard, smelt or touched by the nurse making the entry. Subjective statements and assumptions should be avoided. Information needs to be specific and the nurse must avoid using ambiguous statements in which the meaning is unclear
• When recording subjective data the client’s own words are used whenever possible, using quotation marks to indicate that the statement is a direct quote
• Each entry is signed by the person who records it. Most health care agencies require that a full signature, printed surname and designation is included; for example, Jane Smith (RN Div 2)
• Confidentiality is respected; for example, avoid leaving documentation in an area where it can be read by unauthorised persons. Nurses are legally and ethically required to maintain confidentiality about any information relating to a client
• Transcription of information should be avoided whenever possible, as this practice increases the potential for error to occur (Crisp & Taylor 2005).