Records & Reports.pptx

Records & Reports.pptx

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  Nursing Records & Reports JoshiAbhishek Ashvinbhai Nursing Tutor Gov. College of Nursing Bhavnagar
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  Quote of TheDay TALENT is God-Given Be Thankful…..! FAME is Man-Given Be Grateful……! ATTITUDE & EGO is Self-Given Be Careful….!
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  Content • Introduction • Definitions •Purposes of Recording & Reporting • Types of Records & Reports • General Documentation Guidelines • Conclusion
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  Introduction • All professionalpersons need to be Accountable for the performance of their duties to the public. • Since nursing has been considered as profession, nurses need to record their work on completion. • Records are a practical and indispensable aid to the doctor, nurse and paramedical personnel in giving the best possible service to the clients. • Report summarizes the services of the person or personnel and of the agency.
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  Nursing Records
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  Recording • “A recordis a clinical, scientific, administrative and legal document relating to the nursing care given to the individual family or community.’’ OR • “A record is a permanent written communication that documents information relevant to a client’s health care management.’’
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  Principles of Recording • Specificpurpose which should be clearly understood. • Items on forms and in registers should be conveniently grouped so as to make their completion as easy as possible. • The wording should be easily understood, and where doubt is likely to arise, instructions to facilitate interpretation should be included.
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  Cont… • Adequate supplyof stationery to permit records to be maintained on the proper forms and in the proper registers at all times.
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  Characteristics of Good Recording& Reporting Accuracy Consciousness  Thoroughness Up to date Organization Confidentiality Objectivity
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  Purpose Of Recording  Providedata that are essential for programme planning and evaluation.  Tools of Communication & Dissemination of Information between Different Teams & Departments of an Organization.  Provides Plans for the Future.  Provides Baseline Data to Estimate the Long Term Changes related to the Services.
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  Cont…  Records Helpto Detect Problems.  Provide an Opportunity for Evaluating Services.  Help in the Research for Improvement of Nursing Care.  Help to Meet Legal Requirements & Thus Protect the Workers.
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  Cont….  Records Helpsin Nursing Audits.  Helps in Providing High Standard of Service.  Help in Continuity of Services.  Enable the Person to justify his/her Actions.  Legal documents: poisoning, assault, rape, LAMA, burn etc.
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  Records Maintained in Hospital •The patient’s clinical record • Records of nurses’ observations – Nurses’ Notes • Records of orders carried out • Records of treatment • Records of admission and discharge • Records of equipment loss and replacement ( inventory) • Records of personnel performance.
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  Types of Records 1) Wards Records  2) Nurse’s Records  3) Students Record  4) Staff Records  5) Academic & Administrative Records
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  Nursing Reports
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  Reporting • “It isan Exchange of Information either Verbally OR Written form Between Nurses or Health Team.’’ OR • “Reports are information about a patient either written or oral.’’ -sr. Nancy OR • “A report is a summary of activities or observations seen, performed or heard.’’ -Potter and Perry
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  Cont… • Report Summarizesthe Services of the Person/Personnel of the Agency. • Reports are usually written Daily , Weekly , Monthly , or Yearly.
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  Types of Reports •1) Oral reports : Oral reports are given when the information is for immediate use and not for permanency. E.g. it is made by the nurse who is assigned to patient care, to another nurse who is planning to relieve her. • 2) Written reports : Reports are to be written when the information to be used by several personnel, which is more or less of permanent value, e.g. day and night reports, census, interdepartmental reports, needed according to situation, events and conditions.
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  Purpose of Reporting • Toshow 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 & planning. • To interpret the services to the public and to other interested agencies.
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  Cont…. • They saveDuplication of Efforts & Eliminate the Need for Investigation to Learn the Facts in Situation. • An Essential Tool of Communication between the Patient , Nurse , & Member of the Health Team. • Reports when Complete , Help in Provides better Patient Care.
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  Types Of Reports 1) Change of shift report  2) Transfer reports  3) Incident reports  4) Legal reports
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  General Documentation Guidelines  Ensure thatYou have the Correct Client Record/Chart & that the client’s Name and Identifying Information are on Every Page of the Record.  Be written as soon as possible after an event has happened.  Write Date & Time as well as Sign with your Full Legal Name in Each Entry.
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  Cont…  Do notleave Space between Entries.  Avoid Erasing , Crossing Out , or using Correction Fluid.  If an Error is made while Documenting , Use a Single Line to Cross out the Error, then Date , Time & Sign the Correction ( Acc. To Institutional Policies ).
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  Cont…  Never ChangeAnother Person’s Entry , Even if it is Incorrect.  Use Quotation Marks to Indicate Direct Client Response Ex.- “ I feel Lousy ”  Write Legibly.  Be based on fact, correct and consistent.
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  Cont…  Use aPermanent Ink-pen ( Black is usually preferable Because of it’s Ability to Photocopy well ).  Document in a Complete But Concise manner by using Phrases & Abbreviations as Appropriate.  Document all Telephone calls that You make/Receive that are related to a Client’s case.
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  Conclusion • Maintaining goodquality records and reports has both immediate and long-term benefits for staff .. In the long term it protects individuals and teams from accusations of poor record-keeping, and the resulting drop in morale. It also ensures that the professional and legal standing of nurses are not undermined by absent or incomplete records, if they are called to account at a hearing.