1. The document discusses guidelines for quality documentation and reporting in healthcare settings. It addresses the importance of records for communication, assessment, education, research, auditing, legal purposes and more.
2. Effective record keeping is important for individuals, practitioners, nurses, and authorities. Records provide health histories, guide treatment, show progress, allow for planning and evaluation, and serve administrative and legal needs.
3. Proper documentation includes writing facts based on observations, being accurate, complete, organized and confidential. Records should be maintained according to various principles and guidelines.
The document discusses guidelines for proper documentation and reporting in healthcare, including maintaining accurate, complete records for communication, education, and legal purposes. It also outlines the different types of reports like change of shift reports, incident reports, and legal reports that are important for monitoring quality of care. Proper documentation in medical records is essential for continuity of care, research, and evaluating health programs.
The document discusses guidelines for proper documentation and reporting in healthcare, including maintaining accurate, complete records for communication, education, and legal purposes. It also outlines the different types of reports like change of shift reports, transfer reports, and incident reports that are important for monitoring quality of care. Proper documentation in medical records is essential for continuity of care, research, and legal protection for both patients and providers.
This document discusses teaching practices regarding nursing records and reports. It defines records and reports, outlines their purposes and principles, and describes different types of records including ward records, nurses' records, students' records, and staff records. It also discusses types of reports like change of shift reports and transfer reports. The importance of accurate record keeping for communication, decision making, planning care, and legal documentation is emphasized. Principles of record writing like clarity, accuracy, and confidentiality are covered.
Maintenance of records and reports copySaurav Garg
This document discusses the importance of maintaining accurate and complete records in community health nursing. It outlines the purposes of records such as communication between healthcare providers, planning care, auditing health agencies, research, and education. The document describes different types of records including family records, anecdotal records, clinical records, doctors' order sheets, nurses' sheets, and registers. It provides guidelines for proper recording, including documenting date, time, legibility, permanence, accuracy, and use of accepted terminology. The value of records for nurses, families, doctors, and organizations is explained. Different reports used in community health settings are also outlined.
Computer technology has been used in nursing documentation since the 1960s. Accurate documentation in medical records is critical for proper patient treatment and recovery. Records provide a permanent record of a patient's care and treatment, and support continuity of care between providers. Computers now play a vital role in hospitals by facilitating electronic patient record systems, which collect, store, and make clinical information easily accessible to support efficient patient care and treatment.
This document discusses electronic medical records (EMRs) and patient record systems. It begins by defining an EMR as a digital medical record that allows clinicians to access patient data from any location. It then discusses the types of EMRs including departmental, inter-departmental, and hospital-wide systems. The document also covers electronic health records (EHRs), outlining their definition, structure, users, and components. Key aspects of medical records like purposes, principles of good record keeping, and characteristics of good recording are also summarized.
The document discusses the health record system at the National Cancer Institute in Malaysia. It involves using electronic medical records (EMR) and the FiSiCien system to improve patient care. Patient records are stored securely using a Terminal Digit system and manual filing with pocket files. Records are retrieved upon request for purposes like insurance claims but charges apply. The system aims to complete records within 30 days and properly dispose of records after 7 years.
This document discusses institutional records and reports in nursing. It defines records and reports, outlines their purposes and principles. It describes different types of records including periodic, unit-based, subject-based and collection-based records. Examples of records maintained in community and hospital settings are provided. The uses and importance of maintaining accurate records are explained. Guidelines for improving record keeping are outlined. Reports are defined and their purposes, criteria for a good report, and examples of different types of reports including transfer, incident, and census reports are described. The key points covered are definitions, purposes, principles, types and examples of institutional records and reports in nursing.
The document discusses guidelines for proper documentation and reporting in healthcare, including maintaining accurate, complete records for communication, education, and legal purposes. It also outlines the different types of reports like change of shift reports, incident reports, and legal reports that are important for monitoring quality of care. Proper documentation in medical records is essential for continuity of care, research, and evaluating health programs.
The document discusses guidelines for proper documentation and reporting in healthcare, including maintaining accurate, complete records for communication, education, and legal purposes. It also outlines the different types of reports like change of shift reports, transfer reports, and incident reports that are important for monitoring quality of care. Proper documentation in medical records is essential for continuity of care, research, and legal protection for both patients and providers.
This document discusses teaching practices regarding nursing records and reports. It defines records and reports, outlines their purposes and principles, and describes different types of records including ward records, nurses' records, students' records, and staff records. It also discusses types of reports like change of shift reports and transfer reports. The importance of accurate record keeping for communication, decision making, planning care, and legal documentation is emphasized. Principles of record writing like clarity, accuracy, and confidentiality are covered.
Maintenance of records and reports copySaurav Garg
This document discusses the importance of maintaining accurate and complete records in community health nursing. It outlines the purposes of records such as communication between healthcare providers, planning care, auditing health agencies, research, and education. The document describes different types of records including family records, anecdotal records, clinical records, doctors' order sheets, nurses' sheets, and registers. It provides guidelines for proper recording, including documenting date, time, legibility, permanence, accuracy, and use of accepted terminology. The value of records for nurses, families, doctors, and organizations is explained. Different reports used in community health settings are also outlined.
Computer technology has been used in nursing documentation since the 1960s. Accurate documentation in medical records is critical for proper patient treatment and recovery. Records provide a permanent record of a patient's care and treatment, and support continuity of care between providers. Computers now play a vital role in hospitals by facilitating electronic patient record systems, which collect, store, and make clinical information easily accessible to support efficient patient care and treatment.
This document discusses electronic medical records (EMRs) and patient record systems. It begins by defining an EMR as a digital medical record that allows clinicians to access patient data from any location. It then discusses the types of EMRs including departmental, inter-departmental, and hospital-wide systems. The document also covers electronic health records (EHRs), outlining their definition, structure, users, and components. Key aspects of medical records like purposes, principles of good record keeping, and characteristics of good recording are also summarized.
The document discusses the health record system at the National Cancer Institute in Malaysia. It involves using electronic medical records (EMR) and the FiSiCien system to improve patient care. Patient records are stored securely using a Terminal Digit system and manual filing with pocket files. Records are retrieved upon request for purposes like insurance claims but charges apply. The system aims to complete records within 30 days and properly dispose of records after 7 years.
This document discusses institutional records and reports in nursing. It defines records and reports, outlines their purposes and principles. It describes different types of records including periodic, unit-based, subject-based and collection-based records. Examples of records maintained in community and hospital settings are provided. The uses and importance of maintaining accurate records are explained. Guidelines for improving record keeping are outlined. Reports are defined and their purposes, criteria for a good report, and examples of different types of reports including transfer, incident, and census reports are described. The key points covered are definitions, purposes, principles, types and examples of institutional records and reports in nursing.
This document provides an overview of nursing documentation and record keeping. It defines nursing documentation as any written or electronic information about a client's care. The main purposes of documentation are to facilitate communication, promote good nursing care, and meet professional and legal standards. Key principles of documentation include being comprehensive, ensuring quality and continuity of care, and reflecting current standards. The document also discusses the purposes, types, and importance of nursing records and reports. Accurate documentation and record keeping are essential for communication between healthcare providers, evaluating care quality, and meeting legal requirements.
The document discusses documentation and reporting in nursing. It defines documentation as anything written that describes a client's status or care given. Documentation serves as a permanent record and for purposes like reimbursement, evidence in court, and quality assurance. The principles of documentation include recording date, time, legibility, spelling, permanence, accuracy, sequence, appropriateness, completeness, conciseness, organization, and confidentiality. Records provide information for various parties and purposes like communication, diagnosis, education, and research. Common record forms include flow sheets, admission histories, and patient care summaries.
The document discusses documentation and reporting in healthcare. It defines documentation as a permanent record of client information and care. Documentation serves several purposes such as communication between providers, legal documentation, research, and education. The document outlines various methods of documentation including narrative charting, problem-oriented charting, and computerized documentation. It also discusses different types of records like the kardex, flow sheets, and discharge summary used for recording client data. Verbal reporting is also an important communication technique in healthcare.
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.
Documentation and reporting are important communication techniques for healthcare providers. Documentation provides a written record of interactions between healthcare professionals and clients, as well as test results, treatments, and client responses. Reporting involves sharing client care information between two or more people. The purposes of client records include communication, legal documentation, research, education, quality assurance, and reimbursement. Effective documentation is accurate, complete, organized, and uses common terminology and abbreviations. Common types of records include nursing assessments, care plans, flow charts, and progress notes.
The document discusses nursing records and reports. It defines records as written documentation used for specific purposes that permanently documents patient care information. Reports are defined as oral, written, or computer-based communications intended to convey information. Accurate documentation is important for patient care and treatment. Records must be accurate, complete, confidential, and timely. Effective reporting includes accuracy, organization, and confidentiality. The roles, types, purposes, and principles of nursing records and reports are explained.
Medical Records Department of a 50 bedded Private Hospital Dr. Shruti Aggarwal
The document provides information about medical records at a 50-bed private hospital in Dehradun, India. It discusses the purpose and importance of medical records, describing them as an essential means of communication among healthcare professionals and for ensuring quality of care. It also outlines the infrastructure, staffing, components, constraints, and quality assurance processes involved in managing medical records at the hospital.
nursing records and reports, definition, purposes, principles, values and uses, types, records in hospital, types of reports, how to write better report, nursing responsibilities
Records are an important documentation of an organization's activities and a client's health history. They serve various purposes for individuals, doctors, nurses, and authorities. For nurses specifically, records document the care provided, show progress, and guide professional development. There are different types of records, including clinical, staff, and administrative records. Maintaining accurate, organized records is important and certain principles like confidentiality and objectivity should be followed. Records have legal, educational, and continuity of care uses and are an essential part of providing quality health services.
Nursing documentation is important for several reasons:
1) It helps communicate between the healthcare team and prevents fragmentation, repetition, and delays in patient care.
2) Nursing documentation is used to establish nursing care plans and for auditing, research, education, and reimbursement purposes.
3) Documentation provides a comprehensive view of the patient's condition and treatment and can be used as legal evidence in court cases.
Medical records document a patient's medical history and are important for continuity of care, defending malpractice claims, research, and more. A medical record chronicles a patient's examinations, treatments, test results, medications, and other details. It benefits patients by facilitating further treatment, and benefits doctors, hospitals, and other professionals by allowing them to continue care where others left off. Key characteristics of good medical records include accuracy, completeness, timeliness, and authentication. Issues can include deficiencies, legal and ethical concerns, and challenges maintaining outdated or inactive records.
Medical Records: Intro, importance, characteristics & issuesSrishti Bhardwaj
Unit 1 of MHA SEM- III's syllabus of Medical records Management
(Bharati Vidyapeeth- Center for Health Management Studies & Research, Pune)
Self made- study purpose- reference presentation
avoid hyperlinks on certain slides- inactive
sources shared on last slide as REFERENCES
Hope it helps :)
Records are written documentation that provide important information for healthcare administration and community health. They allow supervisors to learn what is occurring, make decisions, and assess progress towards goals. Reports communicate information between different levels of health services and influence future actions. Both records and reports are essential tools for evaluating health programs and identifying community health problems. They must be accurate, accessible, and useful to healthcare management.
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.
Medical records serve important legal, clinical, and administrative purposes. They provide documentation of a patient's health history and care over time. From a legal standpoint, complete and accurate records can protect healthcare providers in malpractice suits or other legal cases by demonstrating the care and services provided. Medical records also support clinical decision making and are necessary for insurance reimbursement and medical research. Proper management and confidentiality of these sensitive records is crucial.
Tamie Jones is a detail-oriented medical records specialist seeking a position in medical records management. She has over 15 years of experience managing medical records and ensuring compliance. Her skills include medical coding, communication, organization, problem solving, and attention to detail. Her resume lists employment history managing medical records at Reliance House, Partners Pharmacy, and CAP Pharmacy, where her responsibilities included maintaining accurate patient records, training staff, and ensuring privacy and regulatory compliance. She holds an Associate's Degree in Human Services from Middlesex Community College and is pursuing a Bachelor's in Human Services from Post University.
Documentation & Reporting In Nursing Practice.pptxDipon11
This document discusses documentation and reporting in nursing practice. It provides guidelines for proper documentation including using dates, times, legible writing, correct spelling, permanence, accuracy, sequence, appropriateness, completeness, conciseness, organization, and signatures. Documentation serves several purposes such as providing a record of care, guiding reimbursement, and serving as potential legal evidence. Different types of reports in nursing are also outlined including change of shift reports, transfer reports, and incident reports.
Transculturation refers to the merging and converging of cultures as people transition from one culture to another. A transcultural society is one where different cultures, religions and languages coexist with understanding. Characteristics include cultural diversity, freedom and a multicultural nature.
Transculturalism involves cultural fluidity and dynamic changes as groups share their experiences. It is reflexive and points out power relationships through language and history. New identities are continuously created through social and spatial interactions, known as transcultural moments. Factors like migration, transportation, transmitted culture and adapting to new environments influence transcultural societies.
The Transcultural Nursing Society was established in 1975 to improve health worldwide through culturally competent care. Its
This document provides an overview of nursing documentation and record keeping. It defines nursing documentation as any written or electronic information about a client's care. The main purposes of documentation are to facilitate communication, promote good nursing care, and meet professional and legal standards. Key principles of documentation include being comprehensive, ensuring quality and continuity of care, and reflecting current standards. The document also discusses the purposes, types, and importance of nursing records and reports. Accurate documentation and record keeping are essential for communication between healthcare providers, evaluating care quality, and meeting legal requirements.
The document discusses documentation and reporting in nursing. It defines documentation as anything written that describes a client's status or care given. Documentation serves as a permanent record and for purposes like reimbursement, evidence in court, and quality assurance. The principles of documentation include recording date, time, legibility, spelling, permanence, accuracy, sequence, appropriateness, completeness, conciseness, organization, and confidentiality. Records provide information for various parties and purposes like communication, diagnosis, education, and research. Common record forms include flow sheets, admission histories, and patient care summaries.
The document discusses documentation and reporting in healthcare. It defines documentation as a permanent record of client information and care. Documentation serves several purposes such as communication between providers, legal documentation, research, and education. The document outlines various methods of documentation including narrative charting, problem-oriented charting, and computerized documentation. It also discusses different types of records like the kardex, flow sheets, and discharge summary used for recording client data. Verbal reporting is also an important communication technique in healthcare.
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.
Documentation and reporting are important communication techniques for healthcare providers. Documentation provides a written record of interactions between healthcare professionals and clients, as well as test results, treatments, and client responses. Reporting involves sharing client care information between two or more people. The purposes of client records include communication, legal documentation, research, education, quality assurance, and reimbursement. Effective documentation is accurate, complete, organized, and uses common terminology and abbreviations. Common types of records include nursing assessments, care plans, flow charts, and progress notes.
The document discusses nursing records and reports. It defines records as written documentation used for specific purposes that permanently documents patient care information. Reports are defined as oral, written, or computer-based communications intended to convey information. Accurate documentation is important for patient care and treatment. Records must be accurate, complete, confidential, and timely. Effective reporting includes accuracy, organization, and confidentiality. The roles, types, purposes, and principles of nursing records and reports are explained.
Medical Records Department of a 50 bedded Private Hospital Dr. Shruti Aggarwal
The document provides information about medical records at a 50-bed private hospital in Dehradun, India. It discusses the purpose and importance of medical records, describing them as an essential means of communication among healthcare professionals and for ensuring quality of care. It also outlines the infrastructure, staffing, components, constraints, and quality assurance processes involved in managing medical records at the hospital.
nursing records and reports, definition, purposes, principles, values and uses, types, records in hospital, types of reports, how to write better report, nursing responsibilities
Records are an important documentation of an organization's activities and a client's health history. They serve various purposes for individuals, doctors, nurses, and authorities. For nurses specifically, records document the care provided, show progress, and guide professional development. There are different types of records, including clinical, staff, and administrative records. Maintaining accurate, organized records is important and certain principles like confidentiality and objectivity should be followed. Records have legal, educational, and continuity of care uses and are an essential part of providing quality health services.
Nursing documentation is important for several reasons:
1) It helps communicate between the healthcare team and prevents fragmentation, repetition, and delays in patient care.
2) Nursing documentation is used to establish nursing care plans and for auditing, research, education, and reimbursement purposes.
3) Documentation provides a comprehensive view of the patient's condition and treatment and can be used as legal evidence in court cases.
Medical records document a patient's medical history and are important for continuity of care, defending malpractice claims, research, and more. A medical record chronicles a patient's examinations, treatments, test results, medications, and other details. It benefits patients by facilitating further treatment, and benefits doctors, hospitals, and other professionals by allowing them to continue care where others left off. Key characteristics of good medical records include accuracy, completeness, timeliness, and authentication. Issues can include deficiencies, legal and ethical concerns, and challenges maintaining outdated or inactive records.
Medical Records: Intro, importance, characteristics & issuesSrishti Bhardwaj
Unit 1 of MHA SEM- III's syllabus of Medical records Management
(Bharati Vidyapeeth- Center for Health Management Studies & Research, Pune)
Self made- study purpose- reference presentation
avoid hyperlinks on certain slides- inactive
sources shared on last slide as REFERENCES
Hope it helps :)
Records are written documentation that provide important information for healthcare administration and community health. They allow supervisors to learn what is occurring, make decisions, and assess progress towards goals. Reports communicate information between different levels of health services and influence future actions. Both records and reports are essential tools for evaluating health programs and identifying community health problems. They must be accurate, accessible, and useful to healthcare management.
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.
Medical records serve important legal, clinical, and administrative purposes. They provide documentation of a patient's health history and care over time. From a legal standpoint, complete and accurate records can protect healthcare providers in malpractice suits or other legal cases by demonstrating the care and services provided. Medical records also support clinical decision making and are necessary for insurance reimbursement and medical research. Proper management and confidentiality of these sensitive records is crucial.
Tamie Jones is a detail-oriented medical records specialist seeking a position in medical records management. She has over 15 years of experience managing medical records and ensuring compliance. Her skills include medical coding, communication, organization, problem solving, and attention to detail. Her resume lists employment history managing medical records at Reliance House, Partners Pharmacy, and CAP Pharmacy, where her responsibilities included maintaining accurate patient records, training staff, and ensuring privacy and regulatory compliance. She holds an Associate's Degree in Human Services from Middlesex Community College and is pursuing a Bachelor's in Human Services from Post University.
Documentation & Reporting In Nursing Practice.pptxDipon11
This document discusses documentation and reporting in nursing practice. It provides guidelines for proper documentation including using dates, times, legible writing, correct spelling, permanence, accuracy, sequence, appropriateness, completeness, conciseness, organization, and signatures. Documentation serves several purposes such as providing a record of care, guiding reimbursement, and serving as potential legal evidence. Different types of reports in nursing are also outlined including change of shift reports, transfer reports, and incident reports.
Transculturation refers to the merging and converging of cultures as people transition from one culture to another. A transcultural society is one where different cultures, religions and languages coexist with understanding. Characteristics include cultural diversity, freedom and a multicultural nature.
Transculturalism involves cultural fluidity and dynamic changes as groups share their experiences. It is reflexive and points out power relationships through language and history. New identities are continuously created through social and spatial interactions, known as transcultural moments. Factors like migration, transportation, transmitted culture and adapting to new environments influence transcultural societies.
The Transcultural Nursing Society was established in 1975 to improve health worldwide through culturally competent care. Its
1. Cardiogenic shock occurs when the heart is damaged and unable to pump enough blood to vital organs, which can lead to organ failure.
2. It is caused by conditions like heart attack that damage the heart muscle and impair its ability to contract and pump effectively.
3. Symptoms include low blood pressure, confusion, and reduced urine output as the kidneys are not adequately perfused. Treatment focuses on supporting blood pressure and cardiac function through medications, and procedures like coronary interventions can also be used.
This document discusses thalassemia, an inherited blood disorder. It provides details on alpha thalassemia, including that it results from mutations in the genes responsible for the alpha globin component of hemoglobin. Symptoms include anemia, enlargement of the liver and spleen, and heart defects. Treatment involves regular blood transfusions, folate supplements, and chelation therapy to remove excess iron from transfused blood. Key medications discussed are folic acid, used to treat folate deficiency, and deferoxamine, an iron-chelating drug administered via injection to remove excess iron from the body.
The document discusses the management and organization of operating theatres. It defines an operating theatre as a specialized facility in a hospital where invasive surgical procedures are performed under aseptic conditions. It describes the types of surgeries performed, advances in surgery techniques, objectives of maintaining aseptic standards, and the components of an operating theatre complex. It provides guidelines on the number and design of operating theatres, including zoning and cleaning techniques to maintain asepsis.
The document discusses the code of ethics for nursing, including its definition, purposes, uses and ethical principles. It outlines the International Council of Nursing's code of ethics, which has four elements related to nurses and people, practice, the profession and co-workers. The code of ethics for nurses in India is also discussed, covering principles like respecting individuals, maintaining competence, and obligations to practice ethically and work with other health professionals. The code of professional conduct for nurses in India further elaborates on responsibilities, nursing practice, communication and valuing human beings. Autonomy, accountability and assertiveness are also defined.
Rheumatic heart disease is a condition that results from rheumatic fever, which is caused by an untreated streptococcal infection. It involves inflammation and scarring of the heart valves, most commonly affecting the mitral and aortic valves. It is most common in children ages 5-15 from low socioeconomic backgrounds or developing countries. The disease can be managed through antibiotics to prevent recurrent infections, medications to maximize cardiac output and relieve symptoms, and sometimes surgery is needed to repair or replace damaged valves. Nursing care focuses on pain management, monitoring for heart failure, patient education, and reducing anxiety.
Here are the answers to your questions:
1. Sequence of events in hemostasis:
- Vessel wall injury
- Platelet plug formation (aggregation and adhesion)
- Coagulation cascade (conversion of fibrinogen to fibrin)
- Fibrin crosslinking and stabilization of the clot
2. Normal platelet count is 150,000-400,000/mm3
3. Thrombocytopenia is a low platelet count (<150,000/mm3)
4. Platelet deficiency manifests with superficial bleeding rather than deep bleeding.
5. Four important causes of thrombocytopenia in children:
- ITP
- Infections like dengue, malaria
This document discusses illiteracy in India and government initiatives to address it. It begins with defining illiteracy as the inability to read or write a language. It then outlines several programs established by the Indian government to promote literacy, including Sarva Shiksha Abhiyan, Anganwadi Kendra, mid-day meal schemes, and reservations in education. It also discusses the roles of non-governmental organizations like Pratham and scholarships in improving literacy. The document concludes that education empowers people and allows them to think critically.
This document outlines the history and definitions of obstetrics, gynecology, and midwifery. Obstetrics deals with pregnancy and childbirth, gynecology focuses on women's reproductive health, and midwifery provides holistic care for childbearing women and families. Key historical figures include Hippocrates who organized midwife training in ancient Greece, Aristotle who described female pelvic anatomy, and Soranus who was the first to specialize in obstetrics and gynecology by writing the first book on midwifery.
Risk management in healthcare aims to detect, monitor, and prevent risks to patients through clinical and administrative systems and processes. In response to the IOM report "To Err is Human," healthcare organizations implement numerous risk management practices. The Patient Safety and Quality Improvement Act established duties like certifying Patient Safety Organizations to collect and disseminate information on medical errors and establish a patient safety database, with the goal of improving patient safety through confidential reporting of adverse events. Risk management follows five basic steps: establishing the context, identifying risks, analyzing risks through root cause analysis, evaluating risks by scoring likelihood and impact, and treating risks through actions to reduce likelihood and impact.
The document discusses drug abuse rates and health effects globally and among youth in the US. It provides data from the WHO showing the highest drug abuse rates are in the US, Greenland, Mongolia, UK, and New Zealand, ranging from 5.89% to 4.26%. Among youth in the US, marijuana, nicotine, and oxycontin misuse rates increase with each grade from 8th to 12th. Long term drug abuse affects almost every system in the body and can cause cardiac and liver damage, infections, and "meth mouth". It also discusses short and long term cognitive and psychological effects like changes in appetite, sleeplessness, euphoria, and depression.
The document summarizes the key aspects of India's five-year plans from the first plan in 1951 to the twelfth plan. Some of the highlights include:
- The first plan focused on irrigation and agriculture to improve the country's economy and address poverty.
- Later plans emphasized industry, health infrastructure development, poverty alleviation and increasing employment.
- Health budgets and programs expanded over time, with a focus on rural health, communicable diseases, and integrating services.
- Key committees like the Bhore committee influenced the development of primary health centers and an emphasis on preventative healthcare.
The document provides information on bed making procedures and principles in a hospital setting. It discusses the importance of preventing infection transmission, ensuring patient comfort and safety, and using proper body mechanics. The key steps of bed making include preparing clean linens and supplies, explaining the process to the patient, removing dirty linens, dusting the bed, spreading clean sheets and blankets in a specific order, and making the bed neatly before helping the patient back into it.
Fluid and electrolyte balance is crucial for life and homeostasis. Imbalances can result from various factors and are associated with illness. The body maintains balance through complex mechanisms involving the kidneys, lungs, skin, and gastrointestinal tract. Key electrolytes like sodium, potassium, calcium, and hydrogen ions must remain within normal ranges to support cellular functions and metabolism. Disruptions to fluid volume or electrolyte concentrations can cause medical issues. Careful monitoring and targeted treatment strategies aim to restore balance.
The cardiovascular system consists of a network of vessels that circulate blood throughout the body, powered by the heart. Blood flows from the heart through arteries, then smaller arterioles and capillaries where nutrients and oxygen are exchanged, then into venules and veins which return deoxygenated blood back to the heart. The circulatory system is divided into pulmonary circulation from the heart to the lungs to oxygenate blood and systemic circulation from the heart to the rest of the body to deliver oxygenated blood.
This document provides information on a therapeutic cardiac diet, including its goals and recommendations. It defines a heart-healthy diet as high in fruits/vegetables, fiber, and omega-3 fats but low in saturated/trans fats, sodium, sugar, and cholesterol. The goals are to maintain healthy cholesterol and lipid levels. It recommends limiting saturated/trans fats and cholesterol while increasing omega-3 fats. Fiber and potassium also help lower blood pressure. The DASH diet is designed to lower blood pressure through its emphasis on fruits/vegetables, whole grains, and low-fat dairy.
This document outlines the key components of a therapeutic cardiac diet. It defines a heart healthy diet as high in omega-3 fats, fiber, fruits and vegetables and low in saturated and trans fats, sodium, sugar, cholesterol and alcohol. The goals of such a diet are to maintain healthy cholesterol and lipid levels. It recommends limiting saturated fats, trans fats and dietary cholesterol while increasing omega-3 fats. Fiber intake should be between 25-50 grams per day. The DASH diet is also discussed as an eating plan proven to lower blood pressure through limiting sodium and increasing potassium, calcium and magnesium.
This document discusses vital signs including temperature, pulse, respiration, and blood pressure. It provides details on normal ranges, methods of measurement, and factors that impact vital signs assessments. Key points include:
- Vital signs reflect physiological status and health condition. Frequency of assessment depends on patient's condition, being more often for critical patients.
- Normal temperature ranges from 36.4-37.6°C depending on measurement site. Methods include glass, electronic, disposable, and tympanic thermometers.
- Pulse is measured at different sites and normal rate is 60-100 bpm. Characteristics like rhythm, strength and irregularities provide clinical information.
- Respiration rate for adults is 14-
Blood component therapy involves the intravenous administration of whole blood or blood components like red blood cells, platelets, or plasma to treat medical conditions. It is used to increase blood volume after surgery/trauma/hemorrhage, treat severe anemia, infections with low white blood cell count, or bone marrow issues. Proper blood typing and screening is crucial to avoid transfusion reactions. Nurses must carefully monitor patients during transfusions for signs of complications like circulatory overload, allergic reactions, or disease transmission.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
Walmart Business+ and Spark Good for Nonprofits.pdfTechSoup
"Learn about all the ways Walmart supports nonprofit organizations.
You will hear from Liz Willett, the Head of Nonprofits, and hear about what Walmart is doing to help nonprofits, including Walmart Business and Spark Good. Walmart Business+ is a new offer for nonprofits that offers discounts and also streamlines nonprofits order and expense tracking, saving time and money.
The webinar may also give some examples on how nonprofits can best leverage Walmart Business+.
The event will cover the following::
Walmart Business + (https://business.walmart.com/plus) is a new shopping experience for nonprofits, schools, and local business customers that connects an exclusive online shopping experience to stores. Benefits include free delivery and shipping, a 'Spend Analytics” feature, special discounts, deals and tax-exempt shopping.
Special TechSoup offer for a free 180 days membership, and up to $150 in discounts on eligible orders.
Spark Good (walmart.com/sparkgood) is a charitable platform that enables nonprofits to receive donations directly from customers and associates.
Answers about how you can do more with Walmart!"
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
How to Make a Field Mandatory in Odoo 17Celine George
In Odoo, making a field required can be done through both Python code and XML views. When you set the required attribute to True in Python code, it makes the field required across all views where it's used. Conversely, when you set the required attribute in XML views, it makes the field required only in the context of that particular view.
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
Certified as an ISO/IEC 27001: Information Security Management Systems (ISMS) Lead Implementer, Data Protection Officer, and Cyber Risks Analyst, Denis brings a heightened focus on data security, privacy, and cyber resilience to every endeavor.
His expertise extends across a diverse spectrum of reporting, database, and web development applications, underpinned by an exceptional grasp of data storage and virtualization technologies. His proficiency in application testing, database administration, and data cleansing ensures seamless execution of complex projects.
What sets Denis apart is his comprehensive understanding of Business and Systems Analysis technologies, honed through involvement in all phases of the Software Development Lifecycle (SDLC). From meticulous requirements gathering to precise analysis, innovative design, rigorous development, thorough testing, and successful implementation, he has consistently delivered exceptional results.
Throughout his career, he has taken on multifaceted roles, from leading technical project management teams to owning solutions that drive operational excellence. His conscientious and proactive approach is unwavering, whether he is working independently or collaboratively within a team. His ability to connect with colleagues on a personal level underscores his commitment to fostering a harmonious and productive workplace environment.
Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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How to Add Chatter in the odoo 17 ERP ModuleCeline George
In Odoo, the chatter is like a chat tool that helps you work together on records. You can leave notes and track things, making it easier to talk with your team and partners. Inside chatter, all communication history, activity, and changes will be displayed.
How to Fix the Import Error in the Odoo 17Celine George
An import error occurs when a program fails to import a module or library, disrupting its execution. In languages like Python, this issue arises when the specified module cannot be found or accessed, hindering the program's functionality. Resolving import errors is crucial for maintaining smooth software operation and uninterrupted development processes.
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
2. R S MEHTA, MSND 2
RECORDS
A record is a permanent written
communication that documents
information relevant to a client’s
health care management, e.g. a
client chart is a continuing
account of client’s health care
status and need.
-Potter and Perry
3. R S MEHTA, MSND 3
PURPOSES OF RECORDS
1.Supply data that are essential for programme
planning and evaluation.
2.To provide the practitioner with data
required for the application of professional
services for the improvement of family’s
health.
4. R S MEHTA, MSND 4
3.Records are tools of communication
between health workers, the family, and
other development personnel.
4.Effective health records shows the health
problem in the family and other factors that
affect health.
5. A record indicates plans for future.
6.It provides baseline data to estimate the
long-term changes related to services.
5. Administrative purpose of clinical
records
• Legal documents: poisoning, assault, rape,
LAMA, burn etc.
• Research or statistics: rates
• Audit and nursing audit
• Quality of care
• Continuity of care
• Informative purposes: M E N census
• Teaching purpose of students
• Diagnostic purposes: test reports
6. R S MEHTA, MSND 6
Importance of Records in Hospital
1. For the individual and family:
-
-
-
-
Serve the history of the client
Assist in continuity of care
Evidence to support if legal issues arise
Assess health needs, research and
teaching.
7. R S MEHTA, MSND 7
2. For the Doctor:
- Serve the guide for diagnosis, treatment,
follow-up and evaluation.
- Indicate progress and continuity of care.
- Self-evaluation of medical practice
- Protect doctor in legal issues
- Used for teaching and research
8. R S MEHTA, MSND 8
3. For the nurses:
- Document nursing service rendered
- Shows progress
- Planning and evaluation of service for future
improvement
- Guide for professional growth
- Judge the quality and quantity of work done
- Communication tool between nurse and other
staff involved in the care.
- Indicate plan for future
9. R S MEHTA, MSND 9
4. For authorities:
- Statistical information
- Administrative control
- Future reference
- Evaluation of care in terms of quality, quantity
and adequacy.
- Help supervisor to evaluate service
- Guide staff and students
- Legal evidence of service render by each
employee
- Provide justification of expenditure of funds.
10. R S MEHTA, MSND 10
Purposes of records: summary
1.COMMUNICATION
2.FINANCIAL BILLING
3.EDUCATION
4.ASSESSMENT
5.RESEARCH
6.AUDITING AND MONITORING
7.LEGAL ASPECT
11. R S MEHTA, MSND 11
Records in the nursing office & Unit
- Administrative records: Organogram, job
description, procedure manual
Personnel records: personal files, records
Patient related records: patients records send
to Medical director
Leave record, duty roster, meeting minutes,
budget etc
Miscellaneous: circular, round book, formats etc
-
-
-
-
12. R S MEHTA, MSND 12
PRINCIPLES OF RECORD WRITING
1.Nurses should develop their own
method of expression and form in
record writing.
2.Records should be written clearly &
appropriately.
3.Records should contain facts based on
observation, conversation and action.
13. R S MEHTA, MSND 13
4.Select relevant facts and the recording
should be neat, complete and uniform
5.Records should be written immediately
after an interview.
6. Records are confidential documents.
14. R S MEHTA, MSND 14
FILLING OF RECORDS
Different systems may be adopted
depending on the purposes of the records
and on the merits of a system.
The records could be arranged:
– Alphabetically
– Numerically
– Geographically and
– With index cards
15. R S MEHTA, MSND 15
REGISTERS
• It provides indication of the total volume of
service and type of cases seen. Clerical
assistance may be needed for this.
Registers can be of varied types such as:
• immunization register,
• clinic attendance register,
• family planning register,
• birth register and
• death register.
16. R S MEHTA, MSND 16
GUIDELINES FOR QUALITY
DOCUMENTATION AND
REPORTING….
a) Factual basis
b) accuracy
c) completeness
d) accuracy
e) organization
f) confidentiality
17. R S MEHTA, MSND 17
NURSES RESPONSIBILITY FOR
RECORD KEEPING AND REPORTING
• Keep under safe custody of nurses.
• No individual sheet should be separated.
• Not accessible to patients and visitors.
• Strangers is not permitted to read records.
• Records are not handed over to the legal
advisors without written permission of the
administration.
• Handed carefully, not destroyed.
18. R S MEHTA, MSND 18
cont..
• Identified with bio-data of the patients
such as name , age, admission number,
diagnosis, etc. (Legal Issues?)
• Never sent outside of the hospital without
the written administrative permission.
19. Patient Verification
• Two identifiers: patient name and date
of birth
• Compare to ID band, consents, diagnostic
images, and all other patient
documentation related to the procedure
20. R S MEHTA, MSND 20
SYSTEM OF MEDICAL RECORD
• In the modern age, Medical Record has its
utility and usefulness and is a very broad
based indicator of patients care.
• The policy is to keep indoor patient Records
for 10 years
• The OPD registers for 5 years
• The record which is register for legal
purposes in Maintained for 10 years or till
final decision at the court of Law.
21. FUNCTIONS OF MEDICAL RECORD DEPARTMENT
1. Daily receipt of case sheets pertaining to
discharge and expired patients from various
wards, there checking and assembly.
2. Daily compilation of Hospital census report.
3. Maintains & retrieval of records for patient
care and research study.
4. Completion and Procession of Hospital
and preparation on different
reports on morbidity and
statistics
periodical
mortality.
22. R S MEHTA, MSND 22
5. Online registration of vital events of
Birth & Death.
6. Issuing Birth & Death certificated up
to one year.
7. Dealing with Medico Legal records
and attending the courts on
summary.
8. Arrangement & Supervision of
enquiry and admission office.
24. R S MEHTA, MSND 24
• 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.
• Thus the data can be obtained continuously and
for a long period.
25. R S MEHTA, MSND 25
NURSING REPORTS
oReports are information about a patient
either written or oral.
-sr. Nancy
oA report is a summary of activities or
observations seen, performed or heard.
-Potter and Perry
26. R S MEHTA, MSND 26
PURPOSES OF WRITING REPORTS
• To show the kind and quantity of service
rendered over to a specific period.
• To show the progress in reaching goals.
• As an aid in studying health conditions.
• As an aid in planning.
• To interpret the services to the public and to
other interested agencies.
27. R S MEHTA, MSND 27
1) Change of shift report
2)telephone reports
3)Telephone orders
4)Transfer reports
5)Incident reports
6)Legal reports
TYPE OF REPORTS
28. R S MEHTA, MSND 28
❑Can be made promptly
❑Clear, concise and complete
❑All pertinent, identifying data included
❑Mention all people concerned, situation
and signature of person making report
❑Easily understood
❑Important points are emphasized
CRITERIA OF GOOD REPORT
29. 29
Key Messages
• Written policies and procedures are
the backbone of the quality system
• Complete quality assurance records
make quality management possible
• Keeping records facilitates meeting
program reporting requirements
30. R S MEHTA, MSND 30
• Records and reports revels the
essential aspects of service in
such logical order so that the
new staff may be able to
maintain continuity of service
to individuals, families and
communities.
33. The IOM 2003 Patient Safety Report describes an EMR as
encompassing:
– “a longitudinal collection of electronic health information
for and about persons
– Immediate electronic access to person- and population-
level information by authorized users;
– Provision of knowledge and decision-support systems
that enhance the quality, safety, and efficiency of patient
care and
– Support for efficient processes for health care delivery.”
What are Electronic Medical Records?
34. The 1997 IOM report “The Computer-Based Patient
Record: An Essential Technology for Health Care”
defines an EMR as:
“A patient record system is a type of clinical
information system, which is dedicated to
collecting, storing, manipulating, and making
available clinical information important to the
delivery of patient care.
The central focus of such systems is clinical data
and not financial or billing information.”
What are Electronic Medical Records?
35. The American Health Information Management
Association defines three essential capabilities of an
EMR:
1. To capture data at the point of care,
2. To integrate data from multiple internal and
external sources, and
3. To support caregiver decision making.
What are Electronic Medical Records?
36. Leadership Sup ort
Optimum User Adoption
&CustomerROI
Pre-
Implementation
Go Live &
Sup ort
Peer Mentor &
Training
Change
Management
Implementing an EMR in LTC
A c o u n t
Management
37. Records Should be Permanent,
Secure, Traceable
• Permanent:
– Keep books bound
– Number pages
– Use permanent ink
– Control storage
• Secure:
– Maintain confidentiality
– Limit access
– Protect from
environmental hazards
• Traceable:
– Sign and date every
record
RECORDS
37
38. 38
Summary
• What is the difference between a document and
a record?
• What are some examples of documents and
records?
• Name examples of information not found in a
manufacturer product insert.
• What are some key features of SOPs?
• What are some tips for good record-keeping?
• How should records be maintained?
• How are test site records reported in your
country?
39. Transfer of Patients
• Transferring unit will change the status of any
appropriate interventions from “Active” to
“Complete” by clicking in the Status column
– Completed Admissions Documentation
– System Flowsheet
• Receiving unit stops all nursing orders initiated
in order entry, enters transfer orders according
to policy and procedure, and the nurse will add
on the correct system flowsheet for the patient
on the intervention list using the “Add
Intervention” Function
40. Order Entry
• All paper physician order sheets
must be faxed to pharmacy upon
admission
• Pharmacy will enter any medications and IVs
into Meditech – the list of current medications
can be viewed in the EMR by clicking on the
Medications tab
• All non-medication orders will be entered by
the nurse or secretary into the Meditech order
entry system
41. Order Entry
• It is the RN’s responsibility to verify ALL orders
(lab, radiology, nursing, etc.) are entered into
Meditech from the Physician Order Sheet (Use
Order History in the EMR)
• Initial each individual order with red ink after
verification that the order is in Meditech
• After all orders have been entered and verified, a
Kardex will be printed from the Meditech desktop
using the Reports button
42. Verification of Physician Orders
• For ancillary department orders requiring
pager notification (Respiratory Therapy)
the time of the page is written on the order
sheet next to the order
• Co-sign each set of
physician orders with
initials, title, date, and time
43. 24-hour Chart Checks
•
•
Performed on 11pm – 7am shift
Review ALL orders written during the
previous 24 hours and verify they are in
Meditech by accessing the EMR (order
history section, sorted by date)
Sign entire physician’s order sheet with
name/initials, title, date and time in red
ink
•
44. Blood Administration
Documentation
• Blood Transfusions are documented as an Intervention
Set, which can be added using the “Add Intervention” link
on the Intervention worklist (search for “set”)
The set is comprised of:
– Blood Administration Verification (completed just prior to starting
infusion)
– Blood Product Infusion (start time and initial rate)
– Infusion Changes (any rate changes during infusion)
– Blood Product Completion (completed at end of infusion)
– Blood Vital Signs (baseline vitals taken at start, then q15min x 2
after initiation, then hourly)
•
45. Documentation of Wounds
• Wounds are documented as an Intervention Set,
which can be added using the “Add Intervention”
link on the Intervention worklist (search for “set”)
• The set is comprised of:
– Wound / Pressure Ulcer Status Assessment: for initial,
weekly, and change of status wound documentation
(more detailed)
– Wound Care / Dressing Change Assessment: for daily
documentation of dressing changes (focused
assessment specifically for dressing changes)
46. Critical Lab Values
Documentation
• The lab will call the nurse (as well as the
physician) responsible for taking care of the
patient with the critical lab value
• The telephonic critical result, upon receipt, will
be read back to the technologist/technician and
documented as having been read back. If that
does not happen, the technologist/technician will
request that the nurse receiving the critical result
read it back.
47. Critical Lab Values
Documentation
Procedure
1. Verify the result by verbally reading the result
back to the technologist/technician
2. Notify the nurse assigned to the patient of the
critical result if she/he was not the one to
receive the telephonic notification.
3. Document receiving the phone call about the
critical value, the critical result, and what you
did about the result on the Critical Lab Values
Intervention in Meditech PCS.
48. Computer Downtime
• In the event of a computer downtime, the
documentation system reverts back to paper (all
paper forms will be stocked on units)
For downtime less than 4 hours (med/surg) and 2
hours (critical care), information that is recorded on
paper will need to be entered into PCS
For downtime exceeding 4 hours (med/surg) and 2
hours (critical care), the paper system will replace
PCS until the end of the shift and until the system is
back up – the only data that must be re-entered into
PCS in this case are the Vital Signs and the I&O, so
the EMR record will be accurate
•
•
49. Discharge Documentation
•
•
The physician writes the discharge instructions
The nurse is responsible for reviewing all instructions
with the patient and obtaining the patient signature
Carenotes can be printed out from the Infoweb (click on
Micromedix link to access) for patient education
The nurse should make sure the patient understands the
complete list of medications the patient is to take once
being discharged (compared to any medications the
patient was taking on admission), as part of the
medication reconciliation process
Original form goes to medical records and a copy is
given to the patient upon discharge
•
•
•
50. What stays on paper?
• Consent forms
• Admission / Transfer Summaries
• OR/Recovery Documentation
• Physician Order Sheets
• Documentation During Patient Codes
• Pre-op Checklist
• Discharge Instructions
• Labor Event – Triage up until Delivery
• Monitoring Strips
51. Documentation Details
• A nurse can skip a question on an
assessment if he/she is unable to assess
the question due to patient condition or if
the question is not applicable for the
patient at that time
• Any retrospective documentation can be
entered up to 3 days following patient
discharge. ?
52. Documentation Details
• Changes to documentation may only be
made by the person who recorded the
documentation
• Partially documented entries,
documentation editing, and undoing
documentation can be completed by
clicking in the History column for the
appropriate intervention
53. SYSTEM OF MEDICAL RECORD
• DEFINITION
Medical Record of the patient stores the
knowledge concerning the patient and his care. It
contains sufficient data written in sequence of
occurrence of events to justify the diagnosis,
treatment and outcome.
In the modern age, Medical Record has its utility
and usefulness and is a very broad based
indicator of patients care.
54. Flow of Medical Record :-
The flow chart of inpatient Medical Record is as
under :-
Central Admission
Office
Wards
Medical Record Department
1. Assembling
2. ADMN. &
Discharge
analysis
3. Storage Area
Afetr completion of
Reccords
Hospital statistics prepared
Monthly/Yearly
Medical Record is filled for perusal of
Patients/claims/research purposes.
55. FILING OF MEDICAL RECORDS
• The inpatients Medical Record is filed by the
serial numbers assigned at central Admitting
Office.
• The Record is bound in bundles 100 each
and are kept year wise according to the serial
number.
RETENTION OF MEDICAL RECORD
• The policy is to keep indoor patient Records
for 10 years
• The OPD registers for 5 years
• The record which is register for legal
purposes in Maintained for 10 years or till
final decision at the court of Law.
56. R S MEHTA, MSND 56
TYPES OF RECORDS
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57. R S MEHTA, MSND 57
2. Family records
• The basic unit of service is the family. All
records, which relate to members of family,
should be placed in a single family folder. This
gives the picture of the total services and helps
to give effective, economic service to the family
as a whole.
• Separate record forms may be needed for
different types of service such as TB, maternity
etc. all such individual records which relate to
members of one family should be placed in a
single family folder.