Record and reports management
- 1. PATIENT RECORD SYSTEM NURSING RECORDS AND REPORTS MANANGEMENT TOPIC DISCUSSION PRASHANT SALVE
- 2. RECORDS PERMANENT WRITTEN COMMUNICATION DOCUMENTS INFORMATION RELEVANT TO CLIENTS HEALTH CARE MANAGEMENT
- 3. RECORDS ACCURATE COMPREHENSIVE FLEXIBLE
- 4. DEFINITION RECORD IS WRITTEN OR COMPUTER BASED USED FOR SPECIFIC PURPOSE IN ANY FORM. THE PROCESS OF MAKING AN ENTRY ON A CLIENT’S RECORD IS CALLED RECORDING OR DOCUMENTATION. HOSPITAL RECORDS MEDICAL RECORDS NURSING RECORDS
- 5. OBJECTIVES OF HOSPITAL RECORDS TO REVIEW PATIENT CARE, TAKE APPROPRIATE CLINICAL DECISIONS AND TO DEVELOP TREATMENT PLAN. TO PROVIDE AN ARCHEVAL AND LEGALLY ACCEPTABLE RECORD. TO PROVIDE MATERIAL FOR RESEARCHERS. TO ACT AS SOURCE OF INFORMATION FOR HEALTH ADMINISTRATORS. TO CARRY OUT THE THINGS IN RIGHT POSSIBLE MANNER. TO USE FOR TEACHING AND DIAGNOSTIC PURPOSES. TO USE FOR LEGAL PURPOSES.
- 6. PURPOSE OF MEDICAL RECORDS TO PATIENTS TO IMPROVE THE PATIENT CARE. TO SERVE TO DOCUMENT CLINICAL CASE HISTORY. IT SERVES TO AVOID OMISSION OR REPETITION. IT ASSISTS IN CONTINUITY OF CARE. IT SERVES AS EVIDENCES- IN MLC IT SUPPLIES INFORMATION TO INSTITUTE AND EMPLOYEES. TO THE HOSPITAL TO DOCUMENT THE TYPE AND QUALITY OF WORK. TO FURNISH PROOF OF TYPES AND QUALITY OF CARE. TO PROTECT HOSPITAL IN LEGAL SITUATION. TO EVALUATE THE PROFICIENCY OF STAFF. TO HELP IN FUTURE PROGRAM PLANNING.
- 7. PURPOSE OF PATIENT RECORDS COMMUNICATION PLANNING CLIENT CARE AUDITING STATISTICAL AND RESEARCH EDUCATION REIMBURSEMENT LEGAL DOCUMENTATION HEALTH CARE ANALYSIS
- 8. FUCTIONS OF RECORDS HELPING TO IMPROVE ACCOUNTABILITY. SHOWING HOW DECISIONS RELATED TO PATIENT CARE ARE MADE. SUPPORTING THE DELIVERY OF SERVICES. SUPPORTING EFFECTIVE CLINICAL JUDGEMENTS AND DECISIONS. MAKING CONTINUITY OF CARE EASIER. PROVIDING DOCUMENTARY EVIDENCES FOR SERVICES DELIVERED. PROMOTING BETTER COMMUNICATION AND SHARING INFORMATION BETWEEN MEMBERS OF MULTI PROFESSIONAL HEALTHCARE TEAM. HELPING TO IDENTIFY THE RISKS, AND ENABLING EARLY DETECTION OF COMPLICATIONS. SUPPORTING CLINICAL AUDIT, RESEARCH, ALLOCATION OF RESOURCES, AND PERFORMANCE PLANNING. HELPING TO ADDRESSE LEGAL PROCESS AND ADDRESSE COMPLAINTS.
- 9. METHODS OF RECORDING NARRATIVE PROBLEM-ORIENTED SOURCE-ORIENTED
- 10. NARRATIVE RECORDING ESSAY FORMAT WRITTEN CONTENT SPECIFIC TO PATIENT CONDITION AND NURSING CARE GIVEN. DRAWBACKS- TIME CONSUMING REPITITION OF INFORMATION.
- 11. PROBLEM ORIENTED RECORDING- EMPHASIZE ON PATIENT’S PROBLEM IT CONSIST OF FOLLOWING SECTIONS- DATABASE PROBLEM LIST NURSING CARE PLAN PROGRESS NOTES
- 12. DATABASE- HISTORY AND PHYSICAL ASSESSMENT NURSE’S ADMISSION HISTORY ONGOING ASSESSMENT DIETICIAN ASSESSMENT LAB REPORTS AND RADIOLOGICAL TEST REPORTS
- 13. PROBLEM LIST I. IDENTICATION OF PROBLEM II. CREATE PROBLEM LIST
- 14. NURSING CARE PLAN ASSESSMENT SUBJECTIVE DATA AND OBJECTIVE DATA NURSING DIAGNOSIS GOAL EXPECTED OUTCOMES INTERVENTIONS RATIONALE EVALUTION
- 15. PROGRESS NOTES S O A P CHARTING P I E CHARTING D A R CHARTING
- 16. S O A P CHARTING S – SUBJECTIVE DATA ( CLIENT VERBATIM) O – OBJECTIVE DATA ( MEASURABLE AND OBSERVABLE) A – ASSESSMENT ( DIAGNOSIS BASED ON DATA) P – PLAN ( WHAT NURSE PLAN TO DO)
- 17. P I E CHARTING P – PROBLEM I – INTERVENTION E - EVALUTION
- 18. D A R CHARTING D – DATA ( BOTH SUBJECTIVE AND OBJECTIVE DATA) A – ACTION (NURSING INTERVENTION) R – RESPONSE ( EVALUTION OF EFFECTIVENESS)
- 19. SOURCE ORIENTED RECORDING SEPARATE SECTION FOR EACH DISCIPLE IT INCLUDES ADMISSION SHEET PHYSICIAN’S ORDER SHEET NURSE’S ADMISSION SHEET MEDICAL HISTORY AND EXAMNATION MEDICATION RECORDS PHYSICIAN’S PROGRESS NOTE C:USERSPRASHANT SALVEDESKTOPNMMC RECORDS AND REPORTS
- 20. PRINICIPLES OF GOOD RECORD KEEPING HANDWRITING SHOULD BE LEGIBLE. ALL ENTRIES TO RECORDS SHOULD BE SIGNED. PUT THE DATE AND TIME ON ALL RECORDS. RECORDS SHOULD BE ACCURATE AND RECORDED IN SUCH A WAY THAT THE MEANING SHOUD BE CLEAR. RECORDS SHOULD BE READABLE. RECORDS SHOULD BE FACTUAL AND NOT INCLUDED UNNECESSARY ABBREVIATIONS, JARGON, MEANINGLESS PHRASES AND IRRELEVANT SPECULATIONS. USE PROFESSIONAL JUDGEMENT TO DECIDE WHAT IS RELEVENT AND WHAT SHOULD BE RECORDED. RECORD DETAILS OF ANY ASSESSMENT AND REVIEWS UNDERTAKEN. INCLUDE DETAILS OF INFORMATION GIVEN ABOUT CARE AND TREATMENT.
- 21. Cont.… RECORDS SHOULD IDENTIFY ANY RISKS/PROBLEMS THAT HAVE ARISEN AND SHOW THE ACTION TAKEN TO DEAL WITH THEM. DO NOT ALTER/DESTROY ANY RECORDS WITHOUT BEING AUTHORIZED TO DO SO. DO NOT FALSIFY RECORDS. BE AWARE OF THE LEGAL REQUIREMENT AND GUIDANCE REGARDING CONFIDENTIALITY OF THE RECORDS. USE ORGANISATIONAL POLICY AND GUIDELINES WHEN USING RECORDS FOR RESEARCH PURPOSE. DO NOT DISCLOSE THE INFORMATION. BE AWARE OF HOW TO USE INFORMATION SYSTEM AND DO NOT SHARE PASSWORD WITH ANY ONE.
- 22. REPORTS
- 23. REPORTS A REPORT IS A SUMMARY OF ACTIVITES OR OBSERVATIONS SEEN,PERFORMED OR HEARD
- 24. DEFINITION OF REPORT REPORT IS ORAL, WRITTEN OR COMPUTER BASED COMMUNICATION INTENDED TO CONVEY INFORMATION TO OTHERS. THESE CAN BE FORMAL OR INFORMAL. REPORTING IS THE PROCESS OF INFORMING THE OTHER STAFF ABOUT THE PATIENTS OR OF OTHER EVENTS. REPORTS IS A SUMMARY OF INFORMATION WHICH DEPICTS PRESENT FACTS RELATED TO PLANNING, COORDINATING, PERFORMANCE AND THE GENERAL STATE OF SERVICES IN AN ORGANISTION.
- 25. OBJECTIVES OF REPORTS IT PRESENTS FACTUAL INFORMATION TO MANAGEMENT AND THEREBY SERVES AS A MEANS OF COMMUNICATION. IT PROVIDES A VALUABLE RECORD OF DOCUMENTS, WHICH ARE, USED IN FUTURE REFERENCE. IT PROVIDES NECESSARY INFORMATION TO DEPARTMENT, CLIENTS AND GENERAL PUBLIC AT LARGE. IT IS HELPFUL IN MEASURING THE PERFORMANCE OF THE EMPLOYEE. IT MAKES VALUABLE AND CONSTRUCTIVE SUGGESTION TO MANAGEMENT.
- 26. METHODS OF REPORTING CHANGE IN SHIFT REPORT TELEPHONE REPORT TRANSFER REPORT INCIDENT REPORT CONFERRING INTRA-DIVISIONAL INTRA- DEPARTMENTAL
- 27. CHANGE IN SHIFT REPORT IT IS A REPORT GIVEN TO ALL NURSES ON THE NEXT SHIFT. ITS PURPOSE IS TO PROVIDE CONTINITY OF CARE FOR CLIENTS BY PROVIDING A QUICK SUMMARY OF CLIENT NEEDS AND DETAILS OF CARE TO BE GIVEN TO THE ON COMING STAFF. POINTS SHOULD BE REMEMBERED.. • Factual, organized and accurate information • Avoid negativity and subjectivity • Be specific and avoid vague terms • Describe presence of all invasive treatment • Focus on abnormal findings.
- 29. TRANSFER REPORT
- 30. INCIDENT REPORT
- 31. INTRA- DIVISIONAL AMONG NURSING STAFF BETWEEN NURSING SISTERS AND STAFF NURSES BETWEEN NURSING SISTER AND MATRON BETWEEN NURSING SISTER AND DOCTORS
- 32. PATIENT RECORD SYSTEM PATIENT RECORD SYSTEM IS MAINTAINED APPROPRIATELY WITH DOCUMENTATION. DOCUMENTATION IS ANY WRITTEN OR ELECTRONICALLY GENERATED INFORMATION ABOUT A CLIENT THAT DESCRIBES THE CARE OR SERVICES PROVIDED TO CLIENT. HEALTH RECORD CAN PAPER OR ELECTRONIC DOCUMENT. NURSING DOCUMENTATION IS REFERRED TO AS THE PROCESS OF MAKING AN ENTRY ON A RECORD, DATA WHICH IS PERTINENT TO PATIENT CARE OR SERVICES PROVIDED TO THE CLIENT.
- 33. TOOLS FOR DOCUMENTATION INITIAL NURSING ASSESSMENT PATIENT CARE SUMMARY NURSING CARE PLAN CRITICAL/COLLABORATIVE PATHWAY PROGRESS NOTES FLOW SHEETS DISCHARGE /TRANSFER SUMMARY HOME HEALTHCARE GUIDELINES