Documenting and reporting

Abstract

After completing this chapter, you will be able to: • List the measures used to maintain the confidentiality of patient records. • Discuss reasons for keeping patient records. • Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerised records, and the case management model. • Explain how various forms in the patient record (e.g. flow sheets, progress notes, care plans, critical pathways, discharge/transfer forms) are used to document steps of the nursing process (assessment, diagnosis, planning, implementation and evaluation). • Compare and contrast the documentation needed for patients in acute care, home health care and long-term care settings. • Identify and discuss guidelines for effective recording that meets legal and ethical standards. • Identify essential guidelines for reporting patient data. • Explain the reason for limiting the use of abbreviations in clinical documentation.