The document outlines the evaluation and documentation processes in nursing services, emphasizing the importance of structured evaluation programs that encompass educational objectives, teaching procedures, student progress, and outcomes. It details the steps for constructing evaluation tests and the principles, methodologies, and criteria for selecting evaluation tools to ensure validity, reliability, and effectiveness. Additionally, it discusses the roles of records and reports in clinical practice to facilitate communication among healthcare professionals, enhance patient care, and maintain standards of nursing documentation.

1. MANAGEMENT OF NURSING
SERVICES IN HOSPITAL AND
COMMUNITY-
EVALUATION
AND
DOCUMENTATION
KULDEEP VYAS
ASST.PROF HOD –
COMMUNITY HEALTH NURSING
DSSNI

2. Evaluation is a process used to
determine what has happened during a
given activity or in an institution.
Evaluation requires many skills that
are as important as other elements of the
instructional process.
A complete evaluation programme
for a teacher of nursing would encompass:
1.educational objectives
2.teaching and learning procedures,
3. students progress and
4. outcomes.
GENERAL EVALUATION PLAN
1.Evaluation is a methodical process
that helps to recognize the extent to
which a student has reached the
educational objectives.
2.The plan should include a list of learning
outcomes and the techniques to be used in
evaluating the outcomes.
3.It must be planned jointly by teachers and
others, including students, involved in the
teaching-learning process.
4. It should be a group activity

3. STEPS IN CONSTRUCTION OF
EVALUATION TESTS
Preliminary Steps
“Groulund" summarized the preliminary
steps required in constructing evaluation
tests as follows:
1.Objectves and specific learning
outcomes must be identified and defined
in terms of desired changes in pupil
behaviour
.
2. Subject matter contents must be outlined.
3.A table of contents that relate to the
subject matter should be developed.
4.Specific test questions should be
constructed in accordance with the table of
specification
Specific Steps
"Heidgerken" listed the specific steps to be
taken in the evaluation procedure as follows:
1. State the starting objectives.
2. Define the expected changes in behaviour.
3.List and briefly describe situations that
contribute to the expression of behaviour.

4. 4. Develop appropriate and systematic
means of electing different kinds of
behaviour implied in the objectives to be
evaluated.
5.Decide again on ways of recording and
summarizing (through scores, rating or
description behaviour as the basis of
evidence collected.
6. Check validity, reliability and difficulty of
the measures used.
7.Establish conditions that permit students
to give their best performance.
8.Assign scores on the basis of the above
steps.
9.Develop methods of interpretation.
Criteria tor Selecting Evaluation Tools or
Devices
Criteria for Selecting
Evaluation Tool:
1.Examining the objectives.
2.Checking validity, reliability, practicability
and usefulness
3. Sampling the content.

5. Evaluation Methodology
There is a certain methodology for
evaluation. Gilberto has outlined steps:
1.Define objectives
2. Plan the evaluation system
3. Prepare
4. Implement
5. Evaluate
PRINCIPLES OF EVALUATION
1.The objectives of evaluation must be
clearly stated before an evaluation is made.
2.Evaluation techniques should be selected
with reference to the purposes to be served.
3.Different kinds of appraisal techniques
4.Adequate use of the appraisal techniques
develops training and knowledge in the
evaluation methods.
5. Appraisal means there is a start but there
is no end in this process

6. 6.Evaluation procedures must contribute to
improving instructions, guidance and
administration.
7.Since evaluation involves obtaining
information about desired behaviour as an
education objective, an appropriate method
of evaluation should be formulated.
8.Through evaluation, it is possible to
estimate the typical reaction of a student
after observing his reactions.
PURPOSES OF EVALUATION
1.Evaluation procedures help students
understand the desired behaviour expected
of them and what they should learn.
2.They help students to identify their
difficulties and problems in learning as well
as their progress they make.
3.They guide the teacher as well as the
students in selecting future learning
programmes.
4.They provide guidance and counseling to
students related to learning.
1. .

7. 5.They help to judge on the
appropriateness and feasibility of determined
objectives.
6.They provide the teacher with clues to
the attentiveness of the course plan and
teaching method.
7.They help to decide promotions and
placements, etc.
8. They help in reporting to parents the
achievement of students.
9.They diagnose each student's strengths
and weaknesses and suggest remedial
measures.
10.They motivate and encourage students
to learn.
11.They determine the level oft knowledge
and understanding of students at various
levels.
12.They gather information needed for
administrative purposes such as selecting
students tor higher courses. They help the
administration determine effectiveness of the
curriculum, its strengths and weaknesses, and
interpret to the public the goals and
accomplishments of the school.

8. CHARACTERISTICS OF EVALUATION
PROCEDURE
I. Essential characteristics
1.Validity
2. Reliability
3. Objectivity
4. Usability
II. Other characteristics
1.Relevance
2. Equilibrium
3. Discrimination
4.Validity: It is the extent wherein legitimacy
is checked, which measures what it really
measures and what it is intended to measure.
5.Reliability: It is the term used to indicate
the consistency with which a test measures
what it is designed to measure.
6.Objectivity: This is the extent wherein
there is equality in competent examiners
who mutually agree on what constitutes a
good answer for each tool used for
evaluation.

9. 4.Usability: This implies factors such as the
time taken to conduct the test, the cost of
using it and practicality for everyday use.
5.Relevance: It is the degree to which the
centres established for selecting questions
conform to the aims of the measuring
instrument.
6.Equilibrium: Achievement of correct
proportion or balance among questions
allotted to each of the objectives of a course
and the tasks included in the test.
7.Discrimination: This refers to the quality
of each element of a measuring instrument
that makes it possible to distinguish between
good and poor students in relation to a
given variable.

10. DOCUMENTATION
Records
Definition of Records
Records are defined as legalized
administrative tools that are formally
applied permanently to document the
provided nursing care.
Purposes of Records
1.They educate nursing and medical
students.
2.They facilitate communication between
the health care team members.
3.They can be used as a reference for
research.
4.They evaluate quality patient care.
5.They assess the condition of patients.
6.They protect the hospital from law suits.

11. T
ypes of Records Used in Clinical Practice
A list of records/ documents maintained in
the ward is given below. Specimen headings
of some of the records are also given:
1.Day and night report book.
2.Temperature, pulse and respiratory
recording book.
3. Treatment book/ injection book.
4. Sponge book.
5. Duty roster for the staff.
6.Instructions book which the head nurse
carries with her when she accompanies the
medical officer on his daily ward rounds.
7.Controlled and local purchase drugs
accounting book, a separate register is
maintained for dangerous drugs.
8.Stock indent ledger (SIL) and dispatch
index ledger (DIL) registers.
9. Dispatch book.
10.Inventories of various stores items held in
charge of the nurse.
11.Breakage book.

12. 12.Memo book or medical officers call
book, especially for the CMO in case his
attention is required in the ward outside
normal working hours
13.T
elephone message book especially
meant for receiving laboratory results of
serious patients urgently.
14. Intake and output chart record.
15.Demand books for various stores, e.g.
medical stores, dry and wet dispensar,
quarter mastr stores and Red Cross stores.
16.Out pass book for male wards.
17.Urine test report and weight record
especially for medical cases.
18.ESR and weight record register for
tuberculosis patients.
19.Complaint book for maintenance and
repairs.

13. 20. Suggestions books for officers and
officers' family ward only.
21. Admission and discharge book.
22. Scale of hospital diets and extras.
23. Standing orders for patients.
24. Fire officers.
25.Instructions for special radiological
examination like intravenous pyelogram,
barium meal, barium enema,
cholecystography and so on.
Reports Definitions of Reports
1.A report is a system of communication
aimed at transferring essential information
necessary for safe and holistic patient care.
2.A report consists of oral or written
exchanges of information shared between
members in the health team in a number of
ways. For instance, a nurse always reports
on patients at the end of a hospital work
shift.

14. Purposes of Reports
1.To communicate progress of the patient's health
status to all nurses in different shifts
2. To prepare staff members for their day's work.
3.To ensure that all members of the health care
team have the same information.
4.To provide quality and continuity of care
from one shift to the next.
5.To show the kind and amount of service
rendered over a specific period.
6. To illustrate progress in reaching goals.
7. T
o act as an aid in studying health conditions.
8. T
o act as an aid in planning.
9. To interpret the services to the public and to
other interested agencies.
10.To help coordinate care given by several
people.
11.To prevent patients from having to repeat
information to each health team member.
12. To promote accuracy in the provision of cure
and lessen the possibility of error.
13.To help the health personnel make the best
use of their time by avoiding overlapping
activities.

15. T
ypes of Oral Reports
1.Reports between the head nurse (nurse in-
charge) and her assistant, e.g. on patients'
conditions treatment, medications, observations,
admissions and discharges.
2.Reports between nurses who are assigned to
bedside care.
3.Reports of staff members to the charge nurse:
during the day and when on duty, e.g. on
patients conditions, results of treatment carried
out, etc.
4.Nurse in-charge reports to bedside nurses, e.g.
on change in orders.
5.Report of the charge nurse to the nurse
supervisor: includes names, diagnosis, treatment
of each patent, condition, problem in nursing
care, complaints, general picture of the unit. i
6. Report of the charge nurse to the clinical
instructor.
7.report of the supervisor to the director of
nursing.
8. report of the charge nurse to the physician,
e.g. on patient's symptoms, results of treatment,
complaints, problems, etc.
9. A report can be given orally in person or by
audiotape. An in-person report permits the nurse
to obtain immediate feedback about unclear or
incomplete information. The report may be
conducted in the conference room or during the
nurse's walking rounds.

16. Types of Written Reports
1.Census report: Daily census or the number
of patients in the nursing unit at midnight.
2.Reports on mistakes and accidents:
Accurate and comprehensive reports on both
the patients charts and the accident report
are essential to protect the hospital
(documentation for legal consequences). For
example, medication errors, falls, refusal or
treatment, consent for treatment,
complications from procedures,
dissatisfaction with care, etc.
3.Interdepartmental reports: For example,
reports to the admitting office and
information desk of patients to be
discharged, medico legal cases, patients
needing social support and extended health
services.

17. NURSING ROUNDS
Nursing rounds are conducted by the head
nurse /nurse teacher with the members of
her staff/ students for a clear understanding
of the disease and the effect of nursing care
for each patient. to be successful every nurse
must be prepared to participate in
discussions on nursing care.
Types of Ward Rounds
1.Rounds with the doctors
2.Rounds to discuss psychological problem
of patients
3. Social service rounds
4. Medical rounds for nurses
5. Rounds with the physical therapists
6. Nursing rounds.
Purposes of Nursing Rounds
1.To observe the physical and mental
condition of the patients and the progress
made from day to day.
2. To observe the work of staff.
3.To make specific observations of patients
and give reports to the doctor.

18. 4.To introduce patients to the personnel
and vice versa.
5. To carry out the plan made for the care of
patients.
6.To evaluate the results of treatment and
patient satisfaction.
7.To ensure that safety measures are
employed for patients and personnel.
8.To orient the nurse/student in taking
charge of the patient's treatment and status
of the patient.
9.To teach nursing students and hospital
staff regarding specific conditions.
10.To check any preventable conditions in
the patient such as bedsore, foot drop, etc.
11.To check the emergency equipment kept
near the patient for safety and working
order.
12.To compare the clinical manifestation of
disease in a patient so that the student gains
better insight.
13.To prescribe any modification in nursing
action.