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Documenting and reporting Pages 104-111 Prepared by: Dr.Reem A.Jarrad Why communication between staff is important? Because it enhances quality and continuity of clients care Definitions of nursing communication methods 1- Discussion: is an informal oral consideration of a subject by two or more health professionals to identify a problem or to develop strategies to resolve one. Definitions of nursing communication methods 2- Report: is oral, written or computer based communication intended to convey information to others. Definitions of nursing communication methods 3- record : is a written or computer based documentation( charting or recording). What are the purposes for using client records? 1- Communication 2- Planning client care 3- Auditing health agencies ( quality assurance) 4- Research 5- Education 6- Legal documentation 7-Health care analysis ( SWOT= strengths, weaknesses , opportunities, and threats) Documentation Systems 1- Source oriented record 2- Problem oriented medical record 3- Pie ( problems, interventions and evaluation) 4- Focus Charting 5- Computerized documentation Note : practice tips for documentation on the bottom of page 108). General Guidelines for recording 1- Date and time 2- Frequency of documenting according to policy and client condition 3- Legibility ( easy to read..) 4- Permanence ( dark ink) 5- Accepted Terminology 6- Correct spelling General Guidelines for recording 7- Signature 8- Accuracy ( how to manage wrong entry?) 9- Sequence (order of occurrence) 10- Appropriateness ( relevant client data only) 11-Conciseness ( Brief recording) 12- Legal caution( look nursing note page 107, right upper border, directly above word reporting) Reporting Definition: to communicate specific information to a person or group of people, whether oral or written. Examples for Reporting 1- Change of Shift Reports 2- Telephone reports 3- Care Plan Conference 4- Nursing Rounds (Pages 107-108) Good luck with first exam - Which will be on the 28-10-2014 The same time and place of the lecture. - Two value- ethics lectures will remain after the exam, and will be included in the second exam Your Tutor