Records and reports are important tools for communication in healthcare. They allow information to be transmitted between members of the healthcare team. Nurses communicate information about a client's condition through accurate maintenance of records and reports to ensure quality care. Records include both periodic and subject-based documentation of a client's medical history, treatment, and other details. Reports summarize healthcare workers' activities and the condition of clients. Proper preparation, maintenance, and use of records and reports is essential for client care, administration, research, and legal purposes.
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.
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,
This document discusses various methods of documenting client records in healthcare settings. It provides details on:
1) Source-oriented records where each department documents in their own section, and problem-oriented medical records (POMR) where data is arranged by client problems.
2) The four components of a POMR - database, problem list, plan of care, and progress notes which can follow a SOAP or SOAPIER format.
3) Other charting methods like PIE (problem, intervention, evaluation) and guidelines for accurate documentation like documenting date/time, signature, legibility, and using approved abbreviations.
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 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.
The document discusses hospital admission and discharge procedures. It defines admission as allowing a client to stay in the hospital for observation, investigations and treatment. Discharge is when a patient leaves the hospital. There are different types of admissions like emergency and elective, and different types of discharges like planned, transfer, absconding, and death.
The roles and responsibilities of nurses during admission include preparing the room, assessing the patient, documenting information, and making the patient comfortable. During discharge, nurses ensure instructions are understood, belongings are returned, documentation is complete, and transportation is arranged. Proper admission and discharge procedures are important for patient safety, continuity of care, and fulfilling legal and nursing principles.
The document defines records and reports, providing principles for maintaining accurate records. It describes different types of records like clinical records, staff records, and administrative records. Records are used for communication, diagnosis, education, research and legal documentation. Reports summarize services and are used for communication, planning, and interpreting services. Different types of reports like 24-hour reports and census reports are described. The responsibilities of nurses in accurate record keeping and reporting are also outlined.
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.
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,
This document discusses various methods of documenting client records in healthcare settings. It provides details on:
1) Source-oriented records where each department documents in their own section, and problem-oriented medical records (POMR) where data is arranged by client problems.
2) The four components of a POMR - database, problem list, plan of care, and progress notes which can follow a SOAP or SOAPIER format.
3) Other charting methods like PIE (problem, intervention, evaluation) and guidelines for accurate documentation like documenting date/time, signature, legibility, and using approved abbreviations.
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 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.
The document discusses hospital admission and discharge procedures. It defines admission as allowing a client to stay in the hospital for observation, investigations and treatment. Discharge is when a patient leaves the hospital. There are different types of admissions like emergency and elective, and different types of discharges like planned, transfer, absconding, and death.
The roles and responsibilities of nurses during admission include preparing the room, assessing the patient, documenting information, and making the patient comfortable. During discharge, nurses ensure instructions are understood, belongings are returned, documentation is complete, and transportation is arranged. Proper admission and discharge procedures are important for patient safety, continuity of care, and fulfilling legal and nursing principles.
The document defines records and reports, providing principles for maintaining accurate records. It describes different types of records like clinical records, staff records, and administrative records. Records are used for communication, diagnosis, education, research and legal documentation. Reports summarize services and are used for communication, planning, and interpreting services. Different types of reports like 24-hour reports and census reports are described. The responsibilities of nurses in accurate record keeping and reporting are also outlined.
This document discusses different methods of nursing documentation. It describes narrative documentation, problem-oriented medical records (POMR), SOAP/IER notes, PIE notes, and focus charting. It also defines different types of nursing diagnoses like actual, risk, and potential complications. Nursing documentation is an important part of ensuring high-quality patient care. Proper documentation includes recording assessments, care provided, and evaluation of outcomes.
The document discusses various health care agencies in India. It outlines the functions of health care agencies as promoting health, preventing illness, and providing curative services, with the aim of reducing mortality and morbidity rates. It then describes different types of health care agencies, including hospital agencies (both private and government), primary health centers, community health centers, rural hospitals, and more. It also discusses day care centers, health insurance schemes like ESI and CGHS, rehabilitation centers, nursing homes, clinics, dispensaries, and more.
Referral system // Community Referral SystemWasim Ak
This document discusses the referral system in healthcare. It defines referral as sending a patient from a facility with fewer resources to one with more resources and specialists. It outlines the purposes of referrals, levels of referral from village to state hospitals, criteria for urgent referrals, and importance of timely referrals. It also describes the roles, functions, and processes involved in preparing, transferring, and documenting patient referrals between different levels of care.
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.
The document outlines several important considerations for hospital construction and design to promote patient health and safety. Hospitals should be built in locations that are elevated, away from noise and other nuisances, and allow for independent access. Design elements like adequate lighting, ventilation, drainage and pest control are emphasized. Specific guidelines are provided for flooring, spacing between beds, window placement, and isolation areas. Construction should also enable easy access to key departments and allow for emergency evacuation when needed.
treatment of minor ailments and managing the emergency is one of the component of PHC and essential for community nurse, in this ppt points are included like principles, classification, general and systemic minor ailment and its management, standing orders, role of CHN.
The document discusses various methods of nursing documentation and recording. It describes the purposes of accurate nursing documentation as communication, legal documentation, nursing audits, education, financial billing, nursing research, and improving the quality of care. The principles of quality documentation include being factual, accurate, complete, current, organized and timely. Common documentation methods discussed are narrative notes, problem-oriented medical records (POMR), source records, charting by exception, and case management plans.
This document discusses India's 3-tier referral system for healthcare and the nurse's role within it. It describes the levels from village to tertiary care and the purposes of referrals for early treatment, cost-effectiveness, and education. The referral process involves selecting cases based on severity, preparing documentation, informing the receiving unit, transporting the patient, and providing feedback. Nurses are responsible for communication, monitoring patients during transfer, collecting records, and properly handing off care. The system aims to efficiently direct patients to the appropriate level of specialized treatment.
This document defines nursing documentation and outlines its importance and guidelines. Documentation involves written records of all patient care and is important for clinical communication, protecting patient rights, and research. Good documentation is factual, accurate, current, organized, and complete. The document reviews methods of documentation including narrative, problem-oriented (SOAP), and computerized documentation. Common documentation forms are also listed such as kardex, flow sheets, and discharge summaries. The objectives are to define documentation, recognize its importance, identify guidelines, review dos and don'ts, list methods, and forms of documentation.
Types of records and common record keeping forms & computerized documenta...Siva Nanda Reddy
Hospital records are broadly classified into four categories: patient clinical records, individual staff records, ward records, and administrative records. Common record forms include admission nursing history forms, flow sheets, graphic records, patient care summaries, standardized care plans, progress notes, and discharge summary forms. The most common documents in a patient's record are the admission sheet, physician's order sheet, nurse's admission assessment, graphic/flow sheets, medical history and examination, nurses' notes, medication records, progress notes, and diagnostic test results.
This document discusses nursing records and reports. It defines records as permanent documentation of a client's health care and reports as summaries of services provided. Records are used to guide care, ensure continuity, and protect from legal issues. They must be factual, objective, dated, and signed. Reports are shared between caregivers and summarize services. Good reports are clear, concise, and prompt. The document outlines the types and importance of both nursing records and reports in hospital and community 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.
Records and reports at the community level provide important health information. Records include individual health cards, family folders, community folders, and national health program records. They are categorized by type (e.g. periodic, unit-based), subject (e.g. medical, social), and collection place (e.g. health centers, with individuals). Important records kept at health centers include family folders, MCH cards, and treatment/referral records. Records kept with patients include health cards and medicine stock registers. Maintaining accurate, organized records and reports is essential for assessing community health, collecting data, planning, and conducting research.
Communication and nurse patient relationshipEkta Patel
This document discusses communication and the nurse-patient relationship. It defines communication and discusses its elements and types, including verbal and non-verbal communication. It also outlines techniques for effective communication, such as listening, clarification, and reflection. Key aspects of the nurse-patient relationship discussed include attending skills like maintaining eye contact and body language. The document provides an overview of the communication process and methods used between nurses and patients.
This document discusses various aspects of nursing documentation including definitions, purposes, principles, types, methods, forms of recording data, consequences of inadequate documentation, definitions of reporting, types of reports, importance of records and reports, definitions of electronic documentation, guidelines for electronic documentation, advantages and disadvantages of electronic documentation, and the role of the nurse manager in documentation. It provides a comprehensive overview of documentation in nursing.
Nurses must provide effective reporting both orally and in writing to ensure continuity of patient care. Common types of reports include change-of-shift reports to pass on important patient information when nurses change shifts, transfer reports which provide details on a patient's condition and treatment when moved between units, incident reports for documenting any unexpected medical events, and telephone reports to communicate time-sensitive patient information. Effective reporting involves concisely relaying objective and relevant details about a patient's status, treatment, and care needs to keep all healthcare providers well-informed.
This document discusses the referral system in healthcare. It defines referral as transferring cases beyond a facility's competence to a higher level facility. The system is vertical, allowing cases to move from village to subcenter to PHC to CHC and so on. The purposes are to provide comprehensive care appropriately and allow access to specialized services. An effective system requires trained staff, equipment, transportation, and collaboration between levels. Nurses play a role in observing patients, identifying the need for referral, assisting with transportation, and providing follow-up care.
The document discusses India's health care delivery system. It outlines the objectives of providing universal access to preventative, curative, and restorative care. The system has three levels - primary, secondary, and tertiary. The primary level includes sub-centers and primary health centers staffed by health workers, assistants, and medical officers. They provide basic services. Secondary levels include community health centers with specialists and diagnostic services. Tertiary levels have district and specialty hospitals. The system also involves private providers, indigenous medicine, and national health programs.
Family health services are the central point of health services.
It is an important component of “Health for All” goal.
Health of each individual affects the health of other member of family.
This document discusses hot and cold applications for therapeutic purposes. Hot applications are used to relieve pain and congestion, provide warmth, and promote healing by increasing blood flow. Cold applications are used to reduce pain, control bleeding and bacteria growth, and decrease inflammation by constricting blood vessels. Both have specific indications and contraindications. Guidelines are provided for safely applying heat or cold to achieve therapeutic benefits while avoiding potential complications like burns or tissue damage.
Record & Reports for Nursing.. In this slide Yo will see: Introduction, Relation of records and reports, records, type of records, design of records, records related to community health nursing, types, uses of reports, essential requirements of records & reports, Preparation and maintenance of records and reports, guidelines while preparing records, guidelines while preparing reports, maintenance of records and reports.
Records and reports ppt kuldeep vyas 2017 KULDEEP VYAS
Records and reports are essential components of health work. Records are documentation that provide information on activities, while reports communicate information between health workers. It is important to properly file, maintain, and utilize records and reports to assess health levels, make decisions, and influence future plans in health services.
This document discusses different methods of nursing documentation. It describes narrative documentation, problem-oriented medical records (POMR), SOAP/IER notes, PIE notes, and focus charting. It also defines different types of nursing diagnoses like actual, risk, and potential complications. Nursing documentation is an important part of ensuring high-quality patient care. Proper documentation includes recording assessments, care provided, and evaluation of outcomes.
The document discusses various health care agencies in India. It outlines the functions of health care agencies as promoting health, preventing illness, and providing curative services, with the aim of reducing mortality and morbidity rates. It then describes different types of health care agencies, including hospital agencies (both private and government), primary health centers, community health centers, rural hospitals, and more. It also discusses day care centers, health insurance schemes like ESI and CGHS, rehabilitation centers, nursing homes, clinics, dispensaries, and more.
Referral system // Community Referral SystemWasim Ak
This document discusses the referral system in healthcare. It defines referral as sending a patient from a facility with fewer resources to one with more resources and specialists. It outlines the purposes of referrals, levels of referral from village to state hospitals, criteria for urgent referrals, and importance of timely referrals. It also describes the roles, functions, and processes involved in preparing, transferring, and documenting patient referrals between different levels of care.
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.
The document outlines several important considerations for hospital construction and design to promote patient health and safety. Hospitals should be built in locations that are elevated, away from noise and other nuisances, and allow for independent access. Design elements like adequate lighting, ventilation, drainage and pest control are emphasized. Specific guidelines are provided for flooring, spacing between beds, window placement, and isolation areas. Construction should also enable easy access to key departments and allow for emergency evacuation when needed.
treatment of minor ailments and managing the emergency is one of the component of PHC and essential for community nurse, in this ppt points are included like principles, classification, general and systemic minor ailment and its management, standing orders, role of CHN.
The document discusses various methods of nursing documentation and recording. It describes the purposes of accurate nursing documentation as communication, legal documentation, nursing audits, education, financial billing, nursing research, and improving the quality of care. The principles of quality documentation include being factual, accurate, complete, current, organized and timely. Common documentation methods discussed are narrative notes, problem-oriented medical records (POMR), source records, charting by exception, and case management plans.
This document discusses India's 3-tier referral system for healthcare and the nurse's role within it. It describes the levels from village to tertiary care and the purposes of referrals for early treatment, cost-effectiveness, and education. The referral process involves selecting cases based on severity, preparing documentation, informing the receiving unit, transporting the patient, and providing feedback. Nurses are responsible for communication, monitoring patients during transfer, collecting records, and properly handing off care. The system aims to efficiently direct patients to the appropriate level of specialized treatment.
This document defines nursing documentation and outlines its importance and guidelines. Documentation involves written records of all patient care and is important for clinical communication, protecting patient rights, and research. Good documentation is factual, accurate, current, organized, and complete. The document reviews methods of documentation including narrative, problem-oriented (SOAP), and computerized documentation. Common documentation forms are also listed such as kardex, flow sheets, and discharge summaries. The objectives are to define documentation, recognize its importance, identify guidelines, review dos and don'ts, list methods, and forms of documentation.
Types of records and common record keeping forms & computerized documenta...Siva Nanda Reddy
Hospital records are broadly classified into four categories: patient clinical records, individual staff records, ward records, and administrative records. Common record forms include admission nursing history forms, flow sheets, graphic records, patient care summaries, standardized care plans, progress notes, and discharge summary forms. The most common documents in a patient's record are the admission sheet, physician's order sheet, nurse's admission assessment, graphic/flow sheets, medical history and examination, nurses' notes, medication records, progress notes, and diagnostic test results.
This document discusses nursing records and reports. It defines records as permanent documentation of a client's health care and reports as summaries of services provided. Records are used to guide care, ensure continuity, and protect from legal issues. They must be factual, objective, dated, and signed. Reports are shared between caregivers and summarize services. Good reports are clear, concise, and prompt. The document outlines the types and importance of both nursing records and reports in hospital and community 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.
Records and reports at the community level provide important health information. Records include individual health cards, family folders, community folders, and national health program records. They are categorized by type (e.g. periodic, unit-based), subject (e.g. medical, social), and collection place (e.g. health centers, with individuals). Important records kept at health centers include family folders, MCH cards, and treatment/referral records. Records kept with patients include health cards and medicine stock registers. Maintaining accurate, organized records and reports is essential for assessing community health, collecting data, planning, and conducting research.
Communication and nurse patient relationshipEkta Patel
This document discusses communication and the nurse-patient relationship. It defines communication and discusses its elements and types, including verbal and non-verbal communication. It also outlines techniques for effective communication, such as listening, clarification, and reflection. Key aspects of the nurse-patient relationship discussed include attending skills like maintaining eye contact and body language. The document provides an overview of the communication process and methods used between nurses and patients.
This document discusses various aspects of nursing documentation including definitions, purposes, principles, types, methods, forms of recording data, consequences of inadequate documentation, definitions of reporting, types of reports, importance of records and reports, definitions of electronic documentation, guidelines for electronic documentation, advantages and disadvantages of electronic documentation, and the role of the nurse manager in documentation. It provides a comprehensive overview of documentation in nursing.
Nurses must provide effective reporting both orally and in writing to ensure continuity of patient care. Common types of reports include change-of-shift reports to pass on important patient information when nurses change shifts, transfer reports which provide details on a patient's condition and treatment when moved between units, incident reports for documenting any unexpected medical events, and telephone reports to communicate time-sensitive patient information. Effective reporting involves concisely relaying objective and relevant details about a patient's status, treatment, and care needs to keep all healthcare providers well-informed.
This document discusses the referral system in healthcare. It defines referral as transferring cases beyond a facility's competence to a higher level facility. The system is vertical, allowing cases to move from village to subcenter to PHC to CHC and so on. The purposes are to provide comprehensive care appropriately and allow access to specialized services. An effective system requires trained staff, equipment, transportation, and collaboration between levels. Nurses play a role in observing patients, identifying the need for referral, assisting with transportation, and providing follow-up care.
The document discusses India's health care delivery system. It outlines the objectives of providing universal access to preventative, curative, and restorative care. The system has three levels - primary, secondary, and tertiary. The primary level includes sub-centers and primary health centers staffed by health workers, assistants, and medical officers. They provide basic services. Secondary levels include community health centers with specialists and diagnostic services. Tertiary levels have district and specialty hospitals. The system also involves private providers, indigenous medicine, and national health programs.
Family health services are the central point of health services.
It is an important component of “Health for All” goal.
Health of each individual affects the health of other member of family.
This document discusses hot and cold applications for therapeutic purposes. Hot applications are used to relieve pain and congestion, provide warmth, and promote healing by increasing blood flow. Cold applications are used to reduce pain, control bleeding and bacteria growth, and decrease inflammation by constricting blood vessels. Both have specific indications and contraindications. Guidelines are provided for safely applying heat or cold to achieve therapeutic benefits while avoiding potential complications like burns or tissue damage.
Record & Reports for Nursing.. In this slide Yo will see: Introduction, Relation of records and reports, records, type of records, design of records, records related to community health nursing, types, uses of reports, essential requirements of records & reports, Preparation and maintenance of records and reports, guidelines while preparing records, guidelines while preparing reports, maintenance of records and reports.
Records and reports ppt kuldeep vyas 2017 KULDEEP VYAS
Records and reports are essential components of health work. Records are documentation that provide information on activities, while reports communicate information between health workers. It is important to properly file, maintain, and utilize records and reports to assess health levels, make decisions, and influence future plans in health services.
This document discusses the importance of maintaining health records for individuals and families at the community level. It outlines the purposes of health records, which include planning programs and evaluating services, providing data to health practitioners, and communicating information between health workers and other personnel. The document describes the types of records maintained at subcenters, including family folders, immunization records, reports on antenatal care and child care services. It emphasizes principles for properly documenting information in records, such as clearly identifying clients, dating entries, and keeping records confidential, organized and up to date. Regular reporting of services provided is also important for interpreting programs to the public and other agencies.
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 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.
This document discusses nursing informatics topics including nursing records and reports, management information systems, electronic health records, telemedicine, and telenursing. It provides definitions and discusses the importance, types, and best practices for nursing records and reports. Records and reports are important for documenting care, communication between providers, and evaluating services. The document also defines management information systems and describes their objectives and importance for supporting strategic goals, planning, and evaluating health programs.
Medical records are an important system for systematically storing patient information to facilitate access when needed. They contain a patient's personal details, medical history, diagnosis, treatment, and doctors' notes. Well-kept medical records help doctors deliver proper treatment and help patients receive the right care. They also provide important data for research and assessing health services. Nepal has begun developing medical record systems, but they are not yet fully established or standardized across hospitals. Proper medical records are crucial for health planning, research, and delivering quality healthcare services.
21st Century Cures Act mandate, came into effect in April, requires open patient access to clinical notes as part of its information blocking prohibition.
Documentation-and-Reporting students sharing.pptAnju Kumawat
This document discusses documentation, recording, and reporting in healthcare. It covers the purposes of documentation which include communication, legal records, audits, research, and education. It describes different types of records like patient records, nursing service records, and nursing education records. Guidelines are provided for recording, including principles of record writing, common record keeping forms, and computerized documentation. Methods of reporting include narrative charting and problem-oriented charting. The purposes of reporting to ensure communication among the healthcare team is also covered.
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 documentation and reporting in healthcare. It covers the purposes of documentation such as communication, legal records, audits, research, and education. It describes different types of records like patient records, nursing records, and academic records. It discusses guidelines for accurate, complete, confidential, and factual documentation. It also covers various types of reports like change of shift reports, transfer reports, and incident reports. The document provides examples of documentation forms and emphasizes the importance of minimizing legal liabilities through thorough documentation.
This document discusses documentation and reporting in healthcare. It defines documentation as communicating facts in writing over time to maintain a history of events. Recording and reporting are also forms of documentation. The purposes of documentation include communication, legal records, audits, research, education, and continuity of care. Different types of records are discussed, including patient records, nursing service records, and nursing education records. Principles of clear and accurate documentation are presented. The document also covers types of reporting, such as shift change reports and transfer reports.
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.
Records and reports maintained in nursing collegeSayan Samanta
Records and reports are important for documenting patient information and communicating within healthcare teams. Records contain a patient's medical history, diagnoses, treatments, and other details. Reports summarize services provided and the status of patients. They are used to coordinate care, plan treatment, and ensure all staff have up-to-date information. Records and reports must be accurate, confidential, and securely stored or transmitted to protect patient privacy and support high-quality care.
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.
9. Documentation, Recording and Reporting.pptxAme Mehadi
This document discusses documentation, reporting, and record keeping in emergency and critical care settings. It covers the purpose of documentation to ensure continuity of care, meet legal requirements, and provide information for research and education. The document outlines various types of records including nursing assessments, care plans, vital signs charts, medication records, incident reports, and informed consent forms. It provides guidance on documentation principles, such as writing objectively, legibly, and avoiding abbreviations. Maintaining accurate and comprehensive patient records is important for patient safety, clinical governance, and potential medico-legal cases.
The document provides information on information education and communication (IEC) in healthcare. It defines IEC as an important tool for health promotion that can create supportive environments and strengthen community action. The document outlines several aims and objectives of IEC, including encouraging healthy lifestyles and promoting proper use of health services. It also discusses principles of health education, methods of effective communication, planning IEC strategies, types of records and their uses, the importance of reports, and responsibilities of nurses.
3. 1st GNM Community H Nsg - unit- 8 - Records & Reports.pptxthiru murugan
Community Health Nursing IRecords and reports
By,
Thiru murugan
Community health nursing – I (1st GNM)
Unit – VIII: Records and reports
Types and uses
Essential requirements of records and reports.
Preparation & Maintenance.
RECORD:
A record is a clinical, scientific, administrative and legal document relating to the nursing care given to the individual family or community.
REPORTS:
Reports are oral or written exchanges of information shared between caregivers or workers in a number of ways
Reports can be compiled daily, weekly, monthly, quarterly and annually.
Report summarizes the services of the nurse and/or the agency.
TYPES OF RECORDS
Periodical
Unit Based
Subject Based
Collection Placed Based
TYPES OF RECORDS
1. Periodical:
Permanent Records (Cumulative)
Temporary Records (casual/daily records)
2. Unit Based:
Individual (individual health cards)
Related to family (family folders)
Related to community (community folders)
3. Subject Based:
Economical (financial structure of family, village)
Social (records of social structure)
Political
Medical and nursing (treatment and medicine records)
4. Collection Placed Based:
Collected at institution (records of hospital/ health centers)
Records to be kept within individual (immunization cards, disease cards)
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.
Keep under safe custody of nurses
No individual sheet should be separated
Not accessible to others until necessary
Strangers are not permitted to read records
Records are not handed over the legal advisors without written permission of the administration
Handed carefully, not destroyed
Identified with bio-data of the patients such as the name, age, admission number, diagnosis, etc. (Legal issues)
Never sent outside of the hospital without the written administrative permission.
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.
This document discusses the assessment and care of patients with altered sensorium or unconsciousness. It covers levels of consciousness from alert to coma and causes such as head injuries or infections. Guidelines are provided for assessing neurological functions, vital signs, respiratory status and other indicators. Potential complications are outlined. The focus is on airway management, preventing further brain injury, treating underlying conditions, maintaining nutrition, hygiene and positioning, and involving family members.
Fever is a protective response by the body to infection or illness and helps fight pathogens. It can be caused by infections, cancers, injuries or other issues. During a fever various body systems are affected like increased heart rate and breathing. There are different types of fevers defined by temperature patterns like intermittent fever with regular spikes. Managing a patient's fever focuses on cooling them through methods like cold compresses, fans, fluids and medication if needed to prevent complications. Vital signs must be monitored closely during fever episodes.
Light is essential for vision but imperfect light can cause health issues and eye damage. There are various ways to measure light, including foot-candles, lumens, and lux. Good lighting is sufficient, uniform, and avoids glare or shadows. Natural light is better than artificial but artificial options include fluorescent and filament lamps. Standards recommend illumination levels of 100-2000 lux for different tasks. Good lighting criteria ensures proper illumination, uniform distribution without too bright light or flickering to prevent eye strain and accidents.
Community health nursing involves caring for the health of communities and populations, not just individuals. It aims to promote health, prevent disease, and meet the nursing needs of communities. Key aspects of community health nursing include providing nursing services in homes, schools, workplaces, and health centers; focusing on individuals, families, and groups rather than just treating people as isolated cases; and utilizing health promotion, education, and coordination of care to meet the needs of populations.
Primary health care (PHC) aims to make essential health services universally accessible and affordable. It was introduced in 1978 with the goal of "Health for All" by 2000. PHC is defined by the WHO as essential care accessible to communities through their participation and affordable at every development stage. The key concepts are being accessible, acceptable, affordable, available, and accountable. PHC's strategies focus on strengthening infrastructure and training more health workers to expand rural services. Its objectives include reducing disease incidence and mortality rates.
This document provides an overview of India's public health system and levels of healthcare. It defines key terms like health, referral system, and levels of care. It describes the primary, secondary, and tertiary levels of care and the facilities at each level. It outlines the public health infrastructure including village health posts, subcenters, PHCs, and CHCs. It discusses the roles of frontline workers like ASHAs, ANMs, and dais. It also covers voluntary agencies, national health programs, private healthcare settings, and indigenous systems of medicine in India.
This document discusses the composition and importance of air, sources and effects of air pollution, and methods for controlling air pollution. It notes that air is made up primarily of nitrogen and oxygen along with smaller amounts of other gases. It is vital for living things but can become polluted through various natural and human activities that negatively impact health. The community health nurse can play a key role in educating the public and facilitating solutions to reduce air pollution.
Primary health care (PHC) aims to make essential health services universally accessible and affordable. It was introduced in 1978 with the goal of "Health for All" by 2000. PHC is defined by the WHO as essential care accessible to communities through their participation and affordable at every development stage. The key concepts are being accessible, acceptable, affordable, available, and accountable. PHC's strategies focus on strengthening infrastructure and training more health workers to expand rural services. Its objectives include reducing communicable diseases and mortality rates among infants and children.
The document discusses homeostasis and fluid balance in the human body. It defines key terms like body fluids, osmosis, diffusion, active and passive transport.
The three main points are:
1) Homeostasis aims to maintain a stable internal environment. It has receptors, control centers and effectors that regulate variables like temperature, water levels, and electrolyte balance.
2) The body has different fluid compartments that move through active transport, diffusion and osmosis. Water balance is maintained through intake, insensible losses, and urine output.
3) Fluid movement across membranes is governed by hydrostatic and oncotic (colloid osmotic) pressures, which work together
The document discusses community health nursing and defines key concepts. It defines a community as a social group determined by geographical boundaries and common values/interests. Community health nursing aims to promote and preserve the health of populations by focusing on individuals, families, and communities. It utilizes health promotion, education, and coordination of care to meet population needs. The objectives of community health nursing include health promotion, disease prevention and control, and rehabilitation.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Mercurius is named after the roman god mercurius, the god of trade and science. The planet mercurius is named after the same god. Mercurius is sometimes called hydrargyrum, means ‘watery silver’. Its shine and colour are very similar to silver, but mercury is a fluid at room temperatures. The name quick silver is a translation of hydrargyrum, where the word quick describes its tendency to scatter away in all directions.
The droplets have a tendency to conglomerate to one big mass, but on being shaken they fall apart into countless little droplets again. It is used to ignite explosives, like mercury fulminate, the explosive character is one of its general themes.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
2. INTRODUCTION
Records and reports are the good tools of communication in any
organization to function efficiently.
Information's are transmitted from downward to upward and from
upward to downward.
Effective communication is vital to the client care among the health
professional. Nurses as a member of the health care team
communicate information's about the client's condition through
records and reports among the health care providers.
Client depends on nurses to communicate about their health
problems to the doctors and other concerned with him for best
quality of care.
It is essential for all the members of health care team to have
accurate practice of maintaining records and reports.
2
BCCN
3. RECORDS
Records are the presentation of facts, figures, date and other
information's in writing .
“ A record is a permanent written presentation of
information”
In health care setting:
A record is a clinical, scientific, administrative and legal
documentation to the nursing care given to the individual, family
and community
Records are practical & Indispensible tools of the doctors, nurses
and other paramedical staff to plan and deliver the best possible care
to the clinic
3
BCCN
4. TYPES OF RECORDS
1. PERIODICAL RECORDS:
(a) Temporary Records ( casual /daily records)
(b) Permanent Records ( Cumulative / continuing records)
Egs 1: Students health records (with immunization, height ,
weight and other health check –up every year on same card . It
helps to review the total history of child/individual and evaluate
progress over a long period)
Egs 2: Cumulative Records ( Learning experience and
improvement through out a course & records of what they learnt)
2. UNIT BASED RECORDS:
Individual records includes individual health record
Family record of family folder
Community records
National Health Program Records
BCCN 4
5. 3. SUBJECT BASED RECORDS:
Medical & nursing records pertaining to the treatment & Medicine
records
Economical records- financial structure of family & village
Social records- records of social structure
Political records
4. COLLECTION PLACE BASED RECORD
Records of hospital & health centers
Immunization card, disease card
BCCN 5
6. DESIGNING OF CARDS/RECORDS
1. FOLDER TYPE:
It’s a broad card which can be folded into many parts.8 or 10, some
pages kept blank for future entries
2. FILE TYPE:
A file is maintained for each patient .
Outer part printed for summarizing information
Periodical data entered in separate papers and inserted into file.
File type records maintained in hospital for patients
3. ENVELOP TYPE
File type closed on 3 sides and kept on one side
Data entered on separate paper , tagged together and inserted into
envelope
BCCN 6
7. RECORDS MAINTAINED HOSPITALS, HEALTH
CENTERS AND AT NURSING EDUCATIONAL
INSTITUTE
HOSPITAL RECORDS
Admission & discharge register of patients
Treatment register
Laboratory investigation register
Staff attendance and leave register
Equipment stock register
Patient day and night report register
Linen register ,Dhobi book and laundry register
Medical officer on call duty register
Drug indent register and maintenance register
Condemnation register
Census Register
BCCN 7
9. PHC RECORDS
General information records
Outdoor patients records
Treatment and referral records
Family welfare records
Vital events records ( birth & Death, Stock register for equipment
and drugs, medicine distribution register)
Mother and child health records ( Antenatal , postnatal and
immunization records)
Infant & Preschool children record
Family folder
Other records are:
Attendance register, medicine stock register, meeting records,
monthly and yearly report register, stationary stock register ,
patients registration records, depot holder record, daily diary
cumulative records, training register.
BCCN 9
10. RECORDS AT SUBCENTER LEVEL
Mother care register
Child care register
Program register
Daily dairy
Review register
Stock register
Monthly report register
Family welfare register
Referral register
School health register
General information register
Eligible Couple register
BCCN 10
11. RECORDS AT VILLAGE LEVEL
Birth and death register
Mother care RECORD REGISTER
Child care record register, growth chart
Immunization register
Eligible register
Eligible couple register
RECORDS IN NURSING EDUCATION PROGRAM
Student Record
Staff record
General school record
STUDENTS RECORD
Admission application forms
Health records
Attendance register
BCCN 11
12. Leave records
Progress reports
Internal Assessment
Clinical experience record
Daily diary
Cumulative records
Anecdotal records
Course plan
Unit Plan
Clinical rotation plan
SNA meeting register
TEACHING FACULTY AND OTHER STAFF RECORDS
Job description
Educational qualification, experience records
BCCN 12
13. Progress record
Leave record
Staff development register
Staff meeting register
GENERAL RECORDS
Inventory register
Records of meeting of University
Council/University inspection register
Dispatch register
Indent register
Philosophy, purpose and curriculum of college
Budget of the college
Sports and extracurricular activities
Copy of the school/college brochure
Various files related to administration
BCCN 13
14. RECORDS TO BE KEPT BY PATIENT
Health records of School going child
Infant health records including immunization
Records of antenatal and postnatal mother
Records of tuberculosis patients
Individual health cards
PRINCIPLES OF WRITING RECORDS
Records should be written immediately, after an event has occurred
Records should be real based on facts , observation, conversation and
action
Only accepted abbreviation should be used
Short and clear sentence to be used
Records should be appropriate , accurate and legible
Records are valuable legal documents so it should be kept confidential
Records should be written with blue ball point ink
Uniformity in writing records should be maintained
BCCN 14
15. USES OF RECORDS
FOR STAFF NURSES/COMMUNITY HEALTH NURSES
Help to plan and implement care to the client
Help to evaluate the care & teaching given to the client
Prevent duplication of work
Help to assess the quality and quantity of care given
Protect in case of legal Issues
Serve as a guide to the professional growth
Help in auditing the nursing care
FOR DOCTORS
Guide for diagnosis , treatment and follow up care
Help in evaluating the patient and continuity of care
Useful for doctors in making research and in medical practice.
BCCN 15
16. FOR HEALTH AGENCY
Records are the proof of services provided by each worker
Help in auditing the care provided to clients
Help the administration in assessing the performance of their own
institution .
Used as an evaluation tool during conferences & meeting
Provides justification of expenditure of funds
Assist in finding out, health problem of community unit
Legal document for community health activities
Assist in determining the need of resources like medicine ,
equipment and manpower
Means of communications between health workers , family and
community.
BCCN 16
17. FOR INDIVIDUALS
Helps to make them aware of their health needs
Serves as a guide for future treatment and care
RELATION OF RECORDS AND REPORTS
Reports are written on the basis of records
Reports can be presented as record
Records are always in written form, whereas, report can be written
as well as verbal
Records can be preserved whereas verbal reports can be forgotten
Both records and reports are SYNONYMOUS and
INTERDEPENDENT
Both are important TOOLS of COMMUNICATION,
MANAGEMENT in hospital and community health centers and
Nursing
BCCN 17
18. REPORTS
Reports are the verbal /written information shared between the
health workers
Reports summarize the activities of nurses and health care workers
TYPES OF REPORTS
Verbal Report
Written Report
BCCN 18
19. VERBAL REPORT
Its convenient for immediate use
Emergency verbal reports are followed by written reports later.
Verbal reports made about complaints for immediate rectification
Types of Verbal Reports:
Report between head nurse and staff nurse
Report between the members of health team
Reports on accident, mistakes and complaints while changing the
shift
Report between student nurses and clinical instructor
BCCN 19
20. Advantages
Helps to deal with emergency when time is premium
Helps in implementing proper care of patients on verbal instructions
Provides feedback
Saves time, build-up confidence and maintain good interpersonal
relation(IPR) among the health professionals
Serve as a primary source of information
Disadvantages
Possibility of mistakes due to wrong interpretation
No proof, personnel can deny what is told
No permanent record is present
Can result in legal problems
Not useful in legal matters
BCCN 20
21. WRITTEN REPORTS
Reports are written when the information has to be used by several
persons which is of permanent value
Egs:
Day and Night report
Census
Interdepartmental reports
Weekly reports
Monthly reports
Special reports on unusual incidents
Accident reports
Evaluation reports
Transfer reports
Legal reports
BCCN 21
22. Uses of reports
Information about condition of the patients &day to day progress of
patients health
Reports are used as an aid in planning patient care
In community, reports help in studying the health problems of an
area so that an appropriate action can be taken to solve
Used in health planning
Shows the kind and amount services rendered in a community
Helps in future budget planning
Serves as a legal document
BCCN 22
23. ESSENTIAL REQUIREMENT OF RECORDS AND REPORTS
Should be filled carefully
Should complete in all details
Proper filling system should be developed for records and reports
Should be easily available on time
Confidential records & reports should be shown to authorized
person only
Should be written with minimum clerical work involved
Confidentiality to be maintained as they get legal importance
Should be placed at definite and safe place
BCCN 23
24. PREPARATION AND MAINTENANCE OF
RECORDS & REPORTS
Preparation of Records:
Records to be filled properly in systematic way to save time &
Energy
Filling of records depend on objective & methods adopted by the
health center or hospital
Some of the methods commonly used are:
Alphabetically
Numerically
Geographically
BCCN 24
25. GUIDELINES WHILE PREPARING RECORDS
Should be clear, appropriate with eligible handwriting
Based on the facts and reality
Short and clear sentences
Acceptable abbreviations and short forms
Special attention on Numbers and Statistics
Should be filled with Royal blue ink as black ink fades away with
time
After filling the records it has to be signed in capital letters by the
same person
GUIDELINES WHILE PREPARING REPORTS
Reports should be writing in such a way that all essential
information can be easily retrieved
Important information should be highlighted
Presentation should be attractive and important points are stressed
BCCN 25
26. Style of report has to be made easy to understand
Vocabulary used should be simple
Reports should be written based on information and supervision
Should be presented correctly to avoid mistakes
Actual facts should be presented and should not involve the
personal feeling
All information and material has top be collected before writing
report
General outline of writing report has to be prepared before writing
report
Printed forms are preferred to save time
BCCN 26
27. MAINTENANCE OF RECORDS AND
REPORTS
In charge nurse has to maintain records and reports under safe
custody due to its legal implication
No room should be left for leakage of information
Nurse should maintain records and reports immediately after an
incident
Written records and reports are maintained in chronological order
for easy access
It has to be maintained carefully to avoid destruction
It has to be protected from mice, termites and insects etc
Records related to medico-legal cases, dying declaration and will
etc has to be handled carefully for giving witness whenever required
BCCN 27
28. Record should be accurate without mistake
MLC records & reports to be kept under lock and key
For destruction of absolute records legally accepted methods to be
used
People get facilities and legal protection on basis of records . In
such cases only written permission of authorized person, xerox copy
of records can be given and entered in the register
BCCN 28