Recording and Reporting in good health care administration depends on accurate records and timely reports to ensure continuity of care, support legal requirements, facilitate research, and guide program planning and evaluation
Definition
Recording
A record is a clinical, scientific, administrative, and legal document relating to the nursing care given to an individual, family, or community.
Reporting
Reporting is the oral or written communication of information shared among caregivers or health workers, usually documented daily, weekly, monthly, or yearly to summarize services and outcomes
Guidelines for Recording and Reporting
- Document the date and time of each recording.
- Follow the institutional policy regarding frequency of recording.
- Ensure legibility and clarity.
- Be factual; record accurately and appropriately.
- Use simple, short sentences and accepted terminologies.
- Information should be complete and organized.
Purposes of Recording
- Supply data essential for program planning and evaluation
- Serve as a tool of communication between health workers, the family, and other personnel
- Indicate plans for future care and interventions
- Provide baseline data to estimate long-term changes related to services
- Offer opportunities for evaluating and improving nursing care
- Support research and teaching activities
Purposes of Reporting
- Show the kind and amount of services rendered over a specified period
- Illustrate progress toward goals and outcomes
- Aid in studying health conditions and trends
- Facilitate planning and resource allocation
- Interpret services to the public and interested agencies
Formats for Reporting
The written report formats vary for procedures and activities institutionally. The formats include the following:
- Narrative.
- SOAPIER or SOAPIE: Subjective, objective, assessment, plans, intervention, evaluation, and revision.
- PIE: Problem, intervention, and evaluation.
- POMR: Problem-oriented medical record.
- DAR: Data, action, and response also called focus charting.
1.Narrative
A story-like format is used to document the assessment and nursing care provided. It is time consuming and tedious and requires effort to comprehend the information.
2.SOAPIER or SOAPIE
This is the most commonly used method.
- S: Subjective
- Record the subjective information.
- Subjective data include anything the patient or family tells you, including pain level, symptoms, family medical history, and feelings or concerns.
- O: Objective
- Write down your observations about the patient’s symptoms.
- A: Assessment
- Your logical conclusion about the cause of the patient’s symptoms.
- P: Plans
- Describe the treatment goal for the patient and strategies for achieving it.
- I: Intervention
- Explain the action performed to meet the goals.
- E: Evaluation
- Describe the results of the interventions.
- R: Revision
- Specify alternative interventions for ineffective treatment.
Do’s and Don’ts
| Do | Don’t |
|---|---|
| Verify patient identity using two identifiers before documenting | Delay documentation—late entries can omit critical details |
| Use clear, concise, and objective language | Include opinions, judgments, or unapproved abbreviations |
| Date, time, sign, and include credentials on every entry | Sign on behalf of others or leave entries unsigned |
| Follow facility-approved forms, templates, or electronic systems | Alter records without proper addenda or authorization |
| Maintain confidentiality by securing records in locked or encrypted systems | Share records without patient consent or clearance |
Best Practices
- Write clearly and objectively
- Record facts, not assumptions
- Ensure timeliness—document as close to the event as possible
- Maintain confidentiality and comply with data protection laws
- Use standardized formats and approved abbreviations
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
Stories are the threads that bind us; through them, we understand each other, grow, and heal.
JOHN NOORD
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