3. The system utilizing one record for home
and clinic services in which home visits are
recorded in red and clinic visit in blue ink
helps coordinate the services and save the
time of the personnel.
4. All the records which relate to members of
one family should be placed in single family
folder. it contains all the individual records
of one family.
5. It is a brief description of an observed
behavior that appears significant for
evaluation purposes done by community
nurse during home visit. It provides
information about one particular incident.
6. It is used in hospital investigations, special
treatments and procedures are written and
signed.
7. Doctor orders regarding medications,
investigations, special treatments and
procedures are written and signed.
8. Nurses notes are a record of treatments and
nursing measures carried out by the nurses,
their effects, the observations made on the
patient
9. TPR chart, lab reports, diet sheet, concern
form, IO chart, anesthesia chart,
physiotherapy sheet and special treatment
sheets, etc.
11. It is used in time of emergency and followed
by a written report later. It is made by the
nurse who is assigned for patient care.
12. It should concentrate on the past, present,
and future state of the patient or event.
13. Nursing supervisor and nursing administration
personnel need to be kept informed of what
is happening in all patient care areas.
14. It helps in planning of healthcare services
and to know about mortality and morbidity
statistics.
15. Writing a detailed report on mistakes or
accidents that has been taken place in the
care of patients should be informed to higher
authority by writing accidental report.
16. At the end of each shift nurses report
information about their assigned clients to
the nurses working on the next shift.
17. It involves communication of information
about clients from the nurse sending to the
nurse on the receiving unit.
18. It includes reports among the members of
the nursing team, reports between the head
nurse and her assistant, reports between
head nurse and nursing superintendent,
reports to the physician and evaluation
reports, etc.
