Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and permanent method for communication.
Reporting refers to exchanging health care data in oral or written form. Reporting and recording involve correct timing and proper documentation. Failure to record and report the necessary information appropriately may be fatal. Time plays a vital role in reporting and recording. All critical, factual data is recorded or stored permanently with ink-written documents or as data in a computer to enable holistic care. Subjective data should be noted with quotations.
Objective and subjective data should be summarized and written clearly. The data delivers a unique sense of the patient's comprehensive, concise, and easily retrievable data. The data should be written legibly with good grammar, and most importantly, only standard medical abbreviations should be used. Data should be presented under clearly marked headings to enhance quick data retrieval.
The use of nonspecific terms subject to individual interpretation, such as adequate, good, average, normal, poor, small, and large, should be avoided. One nurse's assessment of a patient's average fluid intake may vary from another nurse. It is important to use specific terminologies when recording and reporting objective data.
When entering data, do not generalize or compose judgments. Quotation marks can be used for verbatim statements by the patient. The nurse's responsibility is to alert the interdisciplinary team whenever the assessment data indicates a significant difference from the patient baseline, indicating a potentially serious problem.
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