Record keeping

Record Keeping

Reporting and Documenting

Reporting is oral or written account of patient status; between members of health care team. Report should be clear, concise, and comprehensive.

Documenting: patient record/chart provides written documentation of patient's status and treatment

Purpose: continuity of care, legal document, research, statistics, education, audits

What to document: assessment, plan of care, nursing interventions (care, teaching, safety measures), outcome of care, change in status, health care team communication,

Characteristics of documentation: brief, concise, comprehensive, factual, descriptive, objective, relevant/appropriate, legally prudent

Record Keeping

Health records are the means by which information is communicated about clients and means of ensuring continuity of care. The client's medical record is legal document and can be produced in a court as evidence. Records are used as risk management tools and for research purpose. Often the record is used to remind a witness of events surrounding a lawsuit, because several

months or years usually elapse before the suit goes to trial. The effectiveness of record depends up on accuracy and completeness of the record. Anesthetists Nurses need to keep accurate and complete records of care provided to clients.

Insufficient or inaccurate documentation:

• Can constitute negligence and be the basis for tort liability.
• Hinder proper diagnosis and treatment and result injury to the client.

Accurate Record Keeping

Routine pre-anesthesia assessment and intra and post operative anesthetic intervention should be documented properly.

• Use pen rather than pencil during documentation.
• When making correction do not raise the previous draw one line on an old and add correction so the previous remained legible because correction is not for changing.
• Write legibly.
• Document all information
• Add time, date, name and other important information.
• Document all medically related conditions.
• Use specific terms.
• Statements should not be biased.

The Incident Report

An incident report is an agency record of an accident or incident. Whenever a patient is injured or has a potential injury there exist a possibility of a lawsuit, such a report must be recorded.

An incidental report may be written for situations involving a patient, visitors, or employee.

The incident report used to:

• To make all the facts about an accident available to personnel
• To contribute to statistical data about accidents or incidents.
• To help health personnel to prevent future accidents

N.B. the reports should be completed as soon as possible i.e., Within 24 hours of the incident and filed according to agencies policy.

Information to Include in Incident Report

• Identify the client by name and hospitals.
• Give date and time of the incident. Avoid any conclusions or blame. Describe the incident as you saw it even if you your impressions differ from those of others
• Identify all witnesses to incident
• Identify any equipment by number and any medication by name and number.
• Document any circumstance surrounding the incident. For example, that another client is experiencing cardiac arrest.