The document discusses documentation and reporting in nursing. It defines documentation as a permanent record of client information and care, while reporting involves sharing client care information between two or more people. The importance of documenting and reporting for communication, legal purposes, research, education, and quality assurance is explained. Common documentation methods like source-oriented records, problem-oriented records, narrative notes, and computerized charting are described. Guidelines for effective documentation including brevity, accuracy, appropriateness, completeness and confidentiality are also provided.

1. DOCUMENTING and REPORTING Ma. Tosca Cybil A. Torres, RN, MAN

11. TYPES OF RECORDING

15. Methods (STYLES) OF CHARTING

30. REPORTING