The document discusses the importance and purposes of documentation in nursing. Effective documentation allows nurses to communicate about patient care, promotes good nursing practices, and supports meeting legal and professional standards. It should provide an accurate account of assessments, interventions, and patient outcomes. The SOAP format is commonly used to document patient encounters and ensure comprehensive yet concise notes.
nursing records and reports, definition, purposes, principles, values and uses, types, records in hospital, types of reports, how to write better report, nursing responsibilities
Why is there a need for nursing documentation
Good record keeping promotes
Who reads nursing records
What is expected of a registered nurse
Record keeping should demonstrate
Nurses accountability
Legal Matters of Nursing Record's
documentation and reporting is the basic of nursing care and can be used in all health care setting why, how and when to documented that is described in the ppt the nurses and all health care professional for study, examination and application of this knowledge into their clinical practice
nursing records and reports, definition, purposes, principles, values and uses, types, records in hospital, types of reports, how to write better report, nursing responsibilities
Why is there a need for nursing documentation
Good record keeping promotes
Who reads nursing records
What is expected of a registered nurse
Record keeping should demonstrate
Nurses accountability
Legal Matters of Nursing Record's
documentation and reporting is the basic of nursing care and can be used in all health care setting why, how and when to documented that is described in the ppt the nurses and all health care professional for study, examination and application of this knowledge into their clinical practice
QUESTIONAs an advanced practice nurse (APN), it is essential to.docxmakdul
QUESTION:
As an advanced practice nurse (APN), it is essential to understand your medicolegal responsibilities as they relate to coding the services you provide to patients. Improper coding, undercoding, or overcoding can have serious implications for patients, providers, and the provider’s care setting. For this Discussion, you examine potential coding issues in case studies and consider the medicolegal responsibilities of the advanced practice nurse.
To prepare:
· Select one of the provided case studies.
· Review the patient documentation given for the case. Think about medicolegal considerations and the responsibilities of the advanced practice nurse.
· Consider the medical codes selected by the advanced practice nurse. Reflect on how the selections might impact clinical practice and billing. Think about how the impact might differ from primary to acute care settings.
·
By Day 3
Post a brief description of the patient documentation given for the case study you selected. Explain any medicolegal considerations, including the role and responsibilities of the advanced practice nurse. Then, explain how medical coding might impact clinical practice and billing, as well as how implications might differ from primary to acute care settings.
Case Study 1:
Sally Jones, an acute care advanced practice nurse, is making hospital rounds on the same patients her colleague nurse practitioner saw yesterday. Sally had five history and physicals to complete on admissions that came in overnight. At the beginning of her shift, she had to complete two emergency admissions and was then called to intensive care, where she spent most of the afternoon. She had to leave work early because of her husband’s retirement party. Because she knew most of the patients on her rounding list, she decided to visit each patient’s room quickly for about 10 minutes. She coded all of the visits the same way she had done the day before, with codes 99231 and 99232.
ANSWER:
Introduction:
It is no secret that Evaluation and Management (E/M) miscoding and claims have been causing a major problems for the medical industry over the past several years. According to the Department of Health and Human services, there were about $6.7 billion inappropriately pain in 2010, that amounted to 21% of Medicare payments and a staggering 42% of incorrectly coded claims. Medical coding is the transformation of healthcare diagnosis, procedures, medical services and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician’s notes, laboratory, and radiologic results, etc. Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history. 99231 has a problem focused history, a problem focused exam and a straight forward MDM or Medical Decision Making (or of low complexity). 99231 requires documentation ...
Medical Record Audit in Clinical Nursing Units in Tertiary Hospitaliosrjce
IOSR Journal of Nursing and health Science is ambitious to disseminate information and experience in education, practice and investigation between medicine, nursing and all the sciences involved in health care. Nursing & Health Sciences focuses on the international exchange of knowledge in nursing and health sciences. The journal publishes peer-reviewed papers on original research, education and clinical practice.
By encouraging scholars from around the world to share their knowledge and expertise, the journal aims to provide the reader with a deeper understanding of the lived experience of nursing and health sciences and the opportunity to enrich their own area of practice. The journal publishes original papers, reviews, special and general articles, case management etc.
21st Century Cures Act mandate, came into effect in April, requires open patient access to clinical notes as part of its information blocking prohibition.
TMLT's Risk Management team regularly conducts on-site practice reviews to help physicians address their medical liability risks. This presentation summarizes the top 10 most frequent recommendations made in 2017.
Record & Reports for Nursing.. In this slide Yo will see: Introduction, Relation of records and reports, records, type of records, design of records, records related to community health nursing, types, uses of reports, essential requirements of records & reports, Preparation and maintenance of records and reports, guidelines while preparing records, guidelines while preparing reports, maintenance of records and reports.
Role of Medical Transcription for PatientsNancy Hall
Uncover the significance of medical transcription in enhancing patient care through accurate and accessible medical documentation.
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Cardiac conduction defects can occur due to various causes.
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
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2. Documentation is any written or electronically
generated information about a client that
describes the care or service provided to that
client.
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JONES H.M -MBA/DMS 2
3. Documentation allows nurses and other care
providers to communicate about the care
provided.
Documentation also promotes good nursing
care and supports nurses to meet
professional and legal standards.
Through documentation, nurses
communicate their observations, decisions,
actions and outcomes of these actions for
clients.
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JONES H.M -MBA/DMS 3
4. Documentation is about giving an accurate
account of what occurred and when it
occurred. Nurses document information
pertaining to individual clients or groups of
clients.
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JONES H.M -MBA/DMS 4
5. To facilitate communication
Through documentation, nurses
communicate to other nurses and care
providers their assessments about the status
of clients, nursing interventions that are
carried out and the results of these
interventions.
Documentation of this information increases
the likelihood that the client will receive
consistent and informed care or service
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JONES H.M -MBA/DMS 5
6. Thorough and accurate documentation
decreases the potential for
miscommunication and errors.
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JONES H.M -MBA/DMS 6
7. To promote good nursing care
Documentation encourages nurses to assess
client progress and determine which
interventions are effective and which are
ineffective, and identify and document
changes to the plan of care as needed.
Documentation can be a valuable source of
data for making decisions about funding and
resource management as well as facilitating
nursing research,
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JONES H.M -MBA/DMS 7
8. all of which have the potential to improve the
quality of nursing practice and client care.
Individual nurses can use outcome
information or information from a critical
incident to reflect on their practice and make
needed changes based on evidence.
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JONES H.M -MBA/DMS 8
9. To meet professional and legal standards
Documentation is a valuable method for
demonstrating that, within the nurse-client
relationship, the nurse has applied nursing
knowledge, skills and judgment according to
professional standards.
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JONES H.M -MBA/DMS 9
10. The nurse’s documentation may be used as
evidence in legal proceedings such as
lawsuits, coroners’ inquests, and disciplinary
hearings through professional regulatory
bodies.
In a court of law, the client’s health record
serves as the legal record of the care or
service provided.
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JONES H.M -MBA/DMS 10
11. Analysis of the Health Care
The information of the files can assist the
professionals of the health system to point
out the needs of the particular nursing
institution, as well as the hospital’s services.
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JONES H.M -MBA/DMS 11
12. Different hospitals have different protocols
On:
how and who to document on the charts.
Storage of records
How often documentation should be done.
How long the file should be kept in the ward
after patient is discharged or dies.
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JONES H.M -MBA/DMS 12
13. LEGAL DOCUMENTATION:
Legal documentation refers to lawful written
information.
The client’s record is a legal document and it
is acceptable in court as evidence. For
example, the positive laboratory results for
high vaginal swab would be used as evidence
of rape in the court of law especially in this
error of girl child sexual abuse by elderly
men.
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JONES H.M -MBA/DMS 13
14. Compensation
The documentation also assists the client in
obtaining compensation from the public and
private insurances. In order to obtain
compensation, the file of the patient’s clinical
situation should have the right diagnosis.
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JONES H.M -MBA/DMS 14
15. COMMUNICATION
The records serve as the vehicle by which
different health professionals who interact
with clients communicate with each other.
For example, knocking off nurses give a
hand-over at the end of the shift to the
taking over nurses.
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JONES H.M -MBA/DMS 15
16. The knocking-off nurses explain to their
colleagues who are taking over the condition
of the clients in the wards, what type of care
and medication had been administered and
what had been advised to be done for the
client by the Doctor.
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JONES H.M -MBA/DMS 16
17. EDUCATION
Students in health disciplines often use
medical records such as case notes as
educational tools.
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JONES H.M -MBA/DMS 17
18. CONTINUITY OF CARE
It is after going through the past records and
reports that hospital staff refer patients to
other level of care for continuity of healthy
care. For example:
The Healthy post personnel refer pregnant
women with a record of previous cesarean
section to the first level hospital for
continuity of care, that is caesarean section
procedure.
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JONES H.M -MBA/DMS 18
19. Accountability
Records give an account of what the nurse
has been able to do the time they have been
on duty.
With Records and reports available, it is easy
to find out the person responsible for an act
on the client because the records and reports
bear signatures of the caregiver.
The caregiver is made responsible for his/her
action especially in times of mal practice or
negligence.
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JONES H.M -MBA/DMS 19
20. STATISTICS
Statistics refers to a science that obtain facts
from figures.
Statistical information from the client’s records
can help an agency anticipate and plan for
people’s future needs.
For example, the number of admissions, or
births and types of illness can be obtained from
the records. This same data can help the hospital
to plan the type and quantity medicines to buy,
the number of beds to buy, the type of vaccines
to stock etc.
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JONES H.M -MBA/DMS 20
21. QUALITY ASSURANCE MONITORING
The clients record is used to monitor the care
the client is receiving and the competence of
the people giving that care.
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JONES H.M -MBA/DMS 21
22. REFERENCE
Records and reports could be used as
references especially in cases of an epidemic
like cholera, dysentery and sexually
transmitted diseases.
Information from the previous records can be
used as a guide in management or to solve
the problem at hand. For example, the
disease notification records are kept and
used as references for future use.
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JONES H.M -MBA/DMS 22
23. PLANNING:
Planning involves making preparations for
something in advance.
The data obtained from the records and
reports enable the responsible people to plan
health services and to allocate resources.
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JONES H.M -MBA/DMS 23
24. Patient’s file which contains the case notes of
the hospital visit/stay.
Graphic record which indicate body
temperature, pulse respiration, blood
pressure(BP),weight etc.
Fluid balance sheet/record.
Medication records/ Drug charts.
Progress notes.
Discharge records.
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JONES H.M -MBA/DMS 24
25. Progress notes are made based on a
practitioner client encounter.
One of the most widely recommended
methods for documenting a particular client
encounter is the Subjective Objective
Assessment Plan (SOAP) format.
This format is widely used in medical
practices for documenting client encounters.
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JONES H.M -MBA/DMS 25
26. There are many advantages of using the SOAP
format and these include;
encouraging comprehensive records.
reducing unnecessary documentation.
assisting in the organisation of the notes,
saving time, and facilitating rapid and easy
retrieval of information from the record.
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JONES H.M -MBA/DMS 26
27. Subjective Data (S)
Presenting complaint, including the severity
and duration of symptoms;
Whether this is a new concern or an
ongoing/recurring problem;
Changes in the client’s progress or health
status since the last visit;
Past medical history of the client and their
family, where relevant to the presenting
problem;
Salient/important negative responses.
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JONES H.M -MBA/DMS 27
28. Objective Data (O)
Relevant vital signs;
Physical examination appropriate to the
presenting complaint;
Positive physical findings;
Significant negative physical findings as they
relate to the problem.
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JONES H.M -MBA/DMS 28
29. Assessment (A)
Patient risk factors, if appropriate;
Ongoing/recurring health concerns, if
appropriate;
Review of medications, if appropriate;
Review of laboratory and procedure results, if
available;
Review of consultation reports, if available;
Diagnosis, differential diagnosis, or problem
statement in order of probability and
reflective of the presenting complaint.
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JONES H.M -MBA/DMS 29
30. Plan (P)
Discussion of treatment options;
Tests or procedures ordered and explanation
of significant complications, if relevant;
Consultation requests including the reason
for the referral, if relevant;
New medications/remedies/supplements
ordered and/or medication repeats including
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JONES H.M -MBA/DMS 30
31. dosage, frequency, duration and an
explanation of potentially serious adverse
effects;
Any other patient advice or client education
(e.g., diet or exercise instructions,
contraceptive advice);
Follow-up and future considerations
Specific concerns regarding the client
including client refusal to comply with your
suggestions.
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JONES H.M -MBA/DMS 31
32. Written records should be-
Factual, consistent and accurate
Should be complete
Well organised
Written as soon as possible after an event has
occurred, providing current information on
the care & condition of the patient.
Written clearly in such a manner that the text
can not be erased
Accurately dated, timed and signed with the
signature printed alongside the first entry
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JONES H.M -MBA/DMS 32
33. Not include abbreviations, jargon,
meaningless phrases, irrelevant speculation
or offensive subjective statements
Written wherever possible with the
involvement of the patient or carer and in
terms that the patient can understand
Written in pen and not pencil
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JONES H.M -MBA/DMS 33
34. REPORTING
Reporting is meant to communicate specific
information to a person or a group of people.
A report is oral or written or computer based
communication intended to convey
information to others.
A report whether oral or written should be
concise, including pertinent information.
The purpose is to provide a permanent and
accurate record of relevant data.
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JONES H.M -MBA/DMS 34
35. A report is a legal document. It is required by
law to be kept for a period of five (5) years.
The report must have correct spellings,
particularly on drugs and leave no doubt
concerning the information it contains. Only
universally accepted abbreviations must be
used.
It should be signed by the person who has
written it.
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JONES H.M -MBA/DMS 35
36. CHANGE OF SHIFT REPORTS
This is a report given to all nurses on the
next shift.
Its purpose is to provide continuity of care
for clients by giving new care givers a quick
summary of client’s needs and details.
The change of shift report should describe
each client’s health status and lets the staff
on the next shift know what care the client
will require.
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JONES H.M -MBA/DMS 36
37. A written report is made three times daily, in
the morning by the night staff, at midday by
morning staff and in the evening by the
afternoon staff.
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JONES H.M -MBA/DMS 37
38. Handover reports
The nurse taking over the ward must give her
undivided attention to her work, and this
procedure should be conducted in a quiet
manner without unnecessary interruptions.
Any mistakes must be corrected and
clarifications made there and then.
Report should be given from bed to bed
starting with the acutely ill patients.
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JONES H.M -MBA/DMS 38
39. All discharges and transfers and to where, if
relatives have been notified.
All deaths including condition of the client
leading up to death time and doctor called if
relatives notified.
All pre and post-operative clients (at least 48
hours condition on return from theatre,
medication ordered and if given or nay
treatment ordered.
All pre-operative clients for special
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JONES H.M -MBA/DMS 39
40. investigations state preoperative preparations
carried out etc.
All clients in acute conditions.
All clients on blood transfusion or infusion –
length of time when commenced, rate of flow
etc.
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JONES H.M -MBA/DMS 40
41. The important details to be included in the
ward report are:
All admissions, name, age time of admission,
religion, next of kin, diagnosis if seen by a
doctor, any abnormalities and ordered
treatment and investigation to be clearly
stated.
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JONES H.M -MBA/DMS 41
42. All accurately ill clients e.g. recent head
injury, cerebral malaria, intestinal
obstruction, meningitis and acute cardiac
failure.
Clients on special observations or procedures
like strong analgesics, 24 hours urine
collection etc
NB: Observations of the above clients must
be carefully reported, what drugs given,
dosage and time, fluid balance stated.
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JONES H.M -MBA/DMS 42
43. The report particularly on very ill and newly
admitted should be detailed. No personal
comments should be written in the report. A
nurse reports what he/she observes not what
he/she feels about a client.
Remember to sign the report.
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JONES H.M -MBA/DMS 43
44. ADMISSION REPORT
On admission, a detailed ward report should
be written indicating
name, age, sex,
time of admission,
date of admission,
address,
religion,
next of kin,
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JONES H.M -MBA/DMS 44
45. where client is coming from
diagnosis,
bed number
medication client is getting including dosage
and frequency
observations done
investigations done or to be done
general condition of the client
indicate whether the client has been seen by
the Dr or not
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JONES H.M -MBA/DMS 45
46. Progress report
This is a report written on a client who is on the
ward. The nurse’s progress notes provide
information regarding the progress of a patient
towards the establishment of the desirable
results.
It should indicate the progress the client is
making, how the client spent the day, any thing
special about the client eg had diarrhoea,
vomited, has a fever, etc.
The report should also indicate the treatment the
client is getting. All observations done should be
indicated.
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JONES H.M -MBA/DMS 46
47. Incident Report
This is the report of any event that is not
consistent with the routine operation of the
health care unit or care of the patient, e.g.
client falls, client given overdose, needle stick
injury, suicidal attempt, nurses fighting on
duty, nurse beaten on duty etc.
incident report should have a detailed
account of how the event or incident
happened.
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JONES H.M -MBA/DMS 47
48. Transfer report
This is the report which is written when a
client is transferred from one
unit/ward/hospital to another for specialised
care at a different level, e.g. a client being
transferred from intensive care unit to a
general ward. A transfer report can be given
on phone or in person. The following should
be included in the report;
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JONES H.M -MBA/DMS 48
49. Client’s name, age, and medical diagnosis
Summary of the progress the client has made
since admission and the current health status
of the client
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50. Death report
This should include the detail of the client i.e.
name, age, date of admission, diagnosis and
management the client was receiving.
It should include what has been done before
death, the treatment which was being given
and the resuscitations measures carried out.
The time of death and time of certification
should be recorded.
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51. Discharge report.
This report should include all the particulars
of the client (name, age, address, diagnosis
etc), date of admission, and the medication.
Indicate what time the patient was discharged
what medication he/she will take home. Also
indicate if the client is still on the ward or has
gone with the relatives.
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52. The report should also include the type of
discharge e.g. by the MO in charge or by
themselves (LAMA- Leave against medical
advice) where the client or relative sign
against advice of medical personnel.
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53. Health team members consult among
themselves to exchange ideas and
knowledge.
We confer by consultation e.g. writing a
consultation form to a particular dept.
Making referrals.
Case conferences Drs come together and
discuss certain conditions e.g Hospital major
rounds.
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54. Nurses major rounds.
Handover time.
Departmental meetings.
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