This document discusses records, reports, and documentation in nursing. It defines records as permanent documentation of a client's health information, while reports are oral or written communications between caregivers. Records are important for continuity of care, research, and legal purposes. They must be accurate, objective, and kept confidential. Nurses are responsible for maintaining different types of records like patient, staff, and ward records. Reports include shift changes, transfers, and statistical summaries. Good documentation follows principles like being factual, relevant, and updated in a timely manner.
nursing records and reports, definition, purposes, principles, values and uses, types, records in hospital, types of reports, how to write better report, nursing responsibilities
nursing records and reports, definition, purposes, principles, values and uses, types, records in hospital, types of reports, how to write better report, nursing responsibilities
This lesson will help the nursing students to learn and know the nursing records and reports and responsibility of the nurse in maintaining nursing records and reports in various health settings.
Few would disagree that nursing is one of the most underrated professions in modern times. Being a nurse isn’t easy. In fact, it is a field that can be extremely demanding and even unforgiving to those who pursue it. Being around the ailing and the frazzled for long hours and dealing with them patiently day after day can be challenging, to say the least.
Record and Report in Nursing, Principles of Record and Report, Types of Record and Report, Filling of Record, Value and Uses of Record and Report, Guideline for Documentation,
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
Nursing informatics refers to the practice and science of integrating nursing information and knowledge with technology to manage and integrate health information. The goal of nursing informatics is to improve the health of people and communities while reducing costs.
This lesson will help the nursing students to learn and know the nursing records and reports and responsibility of the nurse in maintaining nursing records and reports in various health settings.
Few would disagree that nursing is one of the most underrated professions in modern times. Being a nurse isn’t easy. In fact, it is a field that can be extremely demanding and even unforgiving to those who pursue it. Being around the ailing and the frazzled for long hours and dealing with them patiently day after day can be challenging, to say the least.
Record and Report in Nursing, Principles of Record and Report, Types of Record and Report, Filling of Record, Value and Uses of Record and Report, Guideline for Documentation,
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
Nursing informatics refers to the practice and science of integrating nursing information and knowledge with technology to manage and integrate health information. The goal of nursing informatics is to improve the health of people and communities while reducing costs.
Recording & Reporting is the content which explains about definition, Types, Principles, Purposes and role of nurse in Recording & reporting. It inlcudes practical application of nursing officers role.
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
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
2. INTRODUCTION
All professional persons need to be accountable for
the performance of their duties to the public.
Since nursing has been considered as profession,
nurses need to record their work on completion.
Records are a practical and indispensable aid to
the doctor, nurse and paramedical personnel in
giving the best possible service to the clients.
3. DEFINITION
RECORD
A record is a permanent written communication that
documents information relevant to a client’s health care
management.
A record is a clinical, scientific, administrative and legal
document relating to the nursing care given to the
individual family or community.
REPORT
Reports are oral or written exchanges of information shared
between caregivers or workers in a number of ways.
A report is the summary of the services of person or
personnel and of the agency.
4. Records are a practical and indispensable aid to
doctor, nurse and paramedical personnel in giving
the best possible service to their clients.
Recorded facts have value and scientific accuracy
for more than mere impression of memory and
there are guidelines for better administration of
health services.
5. PURPOSE OF RECORDS
Supply data that are essential for programme planning
and evaluation.
Provide the practitioner with data required for the
application of professional services for the
improvement of family's health.
Tools of communication between health workers, the
family & other development personnel
Effective health records show the health problem in
the family and other factors that affect health.
Indicates plans for future.
Help in the research for improvement of nursing care.
6.
7. PRINCIPLES OF RECORD
WRITING
Nurses should develop their own method of expression and form in
record writing.
Written clearly, appropriately and adequately.
Contain facts based on observation, conversation and action.
Select relevant facts and the recording should be neat, complete
and uniform
Valuable legal documents and so it should be handled carefully, and
accounted for.
Records should be written immediately after an interview.
Records are confidential documents.
Accurately dated, timed and signed
Not include abbreviations, jargon, meaningless phrases
8. Values and uses of records in
hospital or health centre
For the Individual and Family
Records serve to document the history of the
client.
Records assist in the continuity of care.
Records serve as evidence to support or to manage
or face the legal questions that arise.
Records serve to recognize the health needs and
can be used as a research and teaching tool.
9. Values and uses of records in hospital or
health centre Contd…,
For the Doctor
Serves as guide for diagnosis, treatment, follow up
and evaluation of services.
Indicate progress and continuity of care.
Help self evaluation of medical practice.
Protect the doctor in case of legal issues. Records
may be used for teaching and research.
10. Values and uses of records in hospital or
health centre contd…,
For the Nurse
Provide with documentation of services rendered, i.e.
shows health condition of the client.
Provide data essential for planning and evaluation of
services for further improvement.
Serve as a guide for professional growth.
Enable to judge the quality and quantity of work done.
Serve as communication tool between staff and other
members involved in care.
Indicate plans for the future.
11. Values and uses of records in hospital
or health centre Contd..,
For Authorities
Provide the management with statistical
information necessary for decision in regard to
utilization of resources, planning for administrative
control and future references.
Help the supervisor evaluate the services rendered,
teaching done and a person’s action and reactions.
12. Values and uses of records in hospital
or health centre Contd..,
All records contain the following information
1.Patient identification and demographic data
2.Informed consent for treatment and procedures
3.Admission data
4.Nursing diagnoses
5.Record of nursing care treatment and evaluation
6. Medical history
7. Medical diagnoses
8.Physical assessment findings
9.Diagnostic study results
10.Summary of operative procedures
11. Discharge plan and summary
13. TYPES OF RECORD
1. Patient clinical record
2. Individual staff record
3. Ward record
4. Administrative records and educational records
14. COMMON WARD RECORD
1.Patient clinical record
2.Staff patient assignment record
3. Ward indent record
4. Ward inventory record
5. Equipment maintenance record
6. Ward incident record
7. Infection surveillance record
8. Ward quality indicator record
9. Emergency drugs and crash card record
10. Patient admission record
11. Patient discharge/ Shift record
15. The Head Nurse’s Responsibility for
the Clinical Record
Protection from loss
The head nurse is responsible for safeguarding the
patient’s record from loss or destruction. No individual
sheet is separated from the complete record unless, as
with the doctor’s order sheet, it is kept in a special
place where its safety is guarded.
Safeguarding its content
The hospital administration usually has a procedure
with which the head nurse should be familiar for
handling legal matter of this kind. Patient has the right
to insist that his record be confidential.
16. The Head Nurse’s Responsibility for the
Clinical Record Contd...,
Completeness
Compile records with complete identifying data on
each page in the form approved by the hospital. The
two parts of the record for which the nursing service is
universally wholly responsible are the vital sign,
graphic sheet and nurses’ observation or nurses’ notes.
Responsibility for nurses’ notes
The form for nurses’ notes which has been established
by the hospital should be used by all nurses.
17. How to improve record keeping
Get into the habit of using factual, consistent, accurate,
objective and unambiguous patient information
Use your senses to record what you did.
Ensure there is a reasoned rationale (evidence) for any
decision recorded.
Ensure notes are accurately dated, timed, and signed,
with the name printed alongside the entry.
Write the notes, where possible, with the involvement
and understanding of the patient or care taker.
Errors should be corrected by putting a single line
through the incorrect statement and signing and dating
it.
18. How to improve record keeping
Follow the SMART model (Specific, Measurable, Achievable,
Realistic and Time-based) or similar when planning care
Write up notes as soon as possible after an event and, by law,
within 24 hours, making clear any subsequent alterations or
additions
Do not include jargon, meaningless phrases (for example
'slept well'), offensive subjective statements.
It must be clear what was originally written and why it was
changed, therefore correction fluids should not be used.
The NMC's position on abbreviations is that they should not
be used (NMC, 2002c).e.g. 'PT' could mean patient,
physiotherapist or part time; 'BD' could mean twice or brought
in dead.
19.
20. Reports
Reports can be compiled daily, weekly, monthly,
quarterly and annually. Report summarizes the
services of the nurse and/ or the agency. Reports
may be in the form of an analysis of some aspect of
a service. These are based on records and registers
and so it is relevant for the nurses to maintain the
records regarding their daily case load, service load
and activities.
21. Importance of records
Good reports save duplication of effort and
eliminate the need for investigation to learn the
facts in a situation.
Full reports often save embarrassment due to
ignorance of situation.
Patients receive better care when reports are
thorough and give all pertinent data.
Complete reports give a sense of security which
comes from knowing all factors in the situation.
It helps in efficient management of the ward.
22. Criteria for a good report
Reports should be made promptly if they are to serve
their purpose well.
A good report is clear, complete, concise.
If it is written all pertinent, identifying data are include
– the date and time, the people concerned, the situation,
the signature of the person making the report.
It is clearly stated and well organized for easy
understanding.
No extraneous material is included.
Good oral reports are clearly expressed and presented
in an interesting manner. Important points are
emphasized.
23. TYPES OF REPORT
Oral reports :
Oral reports are given when the information is for
immediate use and not for permanency. E.g. it is made
by the nurse who is assigned to patient care, to another
nurse who is planning to relieve her.
Written reports :
Reports are to be written when the information to be
used by several personnel, which is more or less of
permanent value, e.g. day and night reports, census,
interdepartmental reports, needed according to
situation, events and conditions.
24. REPORTS USED IN HOSPITAL
SETTINGS
1.Change- of- shift reports or 24 hours report
Provide only essential background information about
client (name, age sex, diagnosis and medical history)
but do not review all routine care procedures or task.
Identify clients’ nursing diagnosis or health care
problems and other related causes.
Describe objective measurements or observations about
clients’ condition and response to health problems.
Stress recent change, but do not use critical comment
about clients’ behavior.
25. REPORTS USED IN HOSPITAL
SETTINGS Condt…,
Share significant information about family
members, as it relates to clients’ problems.
Continuously review ongoing discharge plan. Do
not engage in gossip.
Describe instructions given in teaching plan and
clients’ response.
26.
27. REPORTS USED IN HOSPITAL
SETTINGS Contd..,
2.Transfer reports
A transfer reports involve communication of information
about clients from the nurse on sending unit to the nurse
on the receiving unit. Nurse should include the following
information. Client’s name, age, primary doctor, and
medical diagnosis.
Summary of medical progress up to the time of transfer.
Current health status- physical and psychosocial.
Current nursing diagnosis or problems and care plan. Any
critical assessment or interventions to be completed shortly.
Needs for any special equipments etc.
28. Contd…,
3. Incident reports
The nurse who witnessed the incident or who found the client at the time
of incident should file the report.
The nurse describes in concise what happened specifically objective terms,
etc.
The nurse does not interpret or attempt to explain the cause of the incident.
The nurse describes objectively the clients, conditions when the incident
was discovered.
Any measures taken by the nurse, other nurses, or doctors at the time of
the incident are reported.
No nurse is blamed in an incident report the report is submitted as soon as
possible.
The nurse should never make photocopy of the incident report.
29. Contd…,
4. Census report
This is a report compiled daily for the number of
patients. Very often it is done at midnight and the
norms are collected by the night supervisor. The
report will show the total number of patients, the
number of admissions, discharges, transfers, births
and deaths. The nurses should remember that a single
mistake in the census figures made buy one of the
nurses make the census report of the entire institution
incorrect.
30. 5.Birth and death report
The nurses are responsible for sending the birth
and death reports to governmental authorities for
registration within the specified time. 6. Anecdotal
report An anecdote is brief account of some
incident. Incident reports and reports on accidents,
mistakes and complaints are legal in nature. A
written record concerning some observation about a
person or about her work is called an anecdote
note.
31. NURSES RESPONSIBILITY IN
WRITING RECORDS AND REPORTS
Before anything can be written clearly, it must be
clear in one’s own mind.
Reports, lacking facts, may be biased or worthless.
Conciseness, accuracy and completeness are
essential to good reports.
It is better to write several reports than one when
there is more than one main subject upon which to
report
32. Contd,…
Use terminology in keeping with the nature of reports:
Short, simple, commonly used words for nontechnical
reports.
Scientific terms when issuing reports to professional
personnel.
Specific rather than general words
Use a single meaningful term rather than phrases.
Observes mechanics of good writing.
Use goods sentences and paragraphs
Observe margins
33. Contd…,
Spell properly; avoid abbreviation except in
clinical charting.
Use correct pronoun
Don’t forget punctuation
Be neat
Write report in a conversational manner.
Date reports
If report is typed by someone else, check it before
signing it.
34. NURSES RESPONSIBILITY FOR
RECORD KEEPING AND REPORTING
The patient has a right to inspect and copy the record
after being discharged
Failure to record significant patient information on the
medical record makes a nurse guilty of negligence.
Medical record must be accurate to provide a sound
basis for care planning.
Errors in nursing charting must be corrected promptly
in a manner that leaves no doubts about the facts.
In reporting information about criminal acts obtained
during patient care, the nurse must reveal such
information only to the police, because it is considered
a privileged communication.
35. Contd…,
FACT Information about clients and their care must be
functional. A record should contain descriptive,
objective information about what a nurse sees, hears,
feels and smells.
ACCURACY A client record must be reliable.
Information must be accurate so that health team
members have confidence in it.
COMPLETENESS The information within a recorded
entry or a report should be complete, containing
concise and thorough information about a client care or
any event or happening taking place in the jurisdiction
of manger.
36. Contd…,
CURRENTNESS Delays in recording or reporting can
result in serious omissions and untimely delays for
medical care or action legally, a late entry in a chart
may be interpreted on negligence.
ORGANIZATION The nurse or nurse manager
communicates information in a logical format or order.
Health team members understand information better
when it is given in the order in which it is occurred.
CONFIDENTIALITY Nurses are legally and ethically
obligated to keen information about client’s illnesses
and treatments confidential.
37. CONCLUSION
Maintaining good quality records and reports has
both immediate and long-term benefits for staff.. In
the long term it protects individuals and teams from
accusations of poor record-keeping, and the
resulting drop in morale. It also ensures that the
professional and legal standing of nurses are not
undermined by absent or incomplete records, if
they are called to account at a hearing.