RECORDS AND REPORTS..pptx NURSING MANAGENT TOPIC
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IN SIMPLE WORD RECORD MEANS DOCUMENTATION ,OR SOME OTHER PERMANENT FORM FOR FUTURE REFERENCE. REPORTS IS WRITTEN OR ORAL COMMUNICATION BETWEEN CAREGIVERS TO SHARING INFORMATION.
RECORDS AND REPORTS..pptx NURSING MANAGENT TOPIC
- 1. RECORDS AND REPORTS PRESENTED BY: SALMA SULTANA
- 2. Introduction Records in an account of something , written to perpetuate knowledge of events . Records and reports and indispensable aids to all who are responsible for giving best possible service to individuals, families and community.
- 3. Definition According to Potter and Perry, A record is permanent written communication that documents information relevant to a clients heatlh care management, Eg: A client chart is a continuing account of clients health care status and need .
- 4. OR A record is a permanent written communication that documents information relevant to a clients health care management.
- 5. Objectives of records To review patient care , make clinical decisions and prepare treatment plans . To provide a legally acceptable record . To provide a source of information for health managers. To carry out the things in the right possible manner
- 6. Purposes Purposes of medical records: To patient :- To improve patient care. To serve to document the clinical history . To provide evidence in medicolegal cases.
- 7. To health organization/hospital:- To record all activities of the health care providers. To furnish proof of kind and quality care. To protect hospital in legal staff. To help in future program planning.
- 8. Others are :- The purposes of records – Communication planning client care auditing health organisation education reimbursement lawful purposes healthcare analysis and evaluation
- 9. Value of nurses clinical records: It provides baseline data For further plan of action and to evaluate the care given. Nursing records , example temperature chart, blood pressure record intake /output records etc are useful for diagnostic and treatment purposes . To assess the workload of nurses and to evaluate the quality of care. Records are beneficial for education, teaching and research proposes.
- 10. Functions of Records:- To help in improving the responsibility and accountability of healthcare providers . To reflect the level of healthcare services and clinical judgement and decisions . to provide a source of patient care and communications . to promote better discussion and coordination among team members
- 11. Principles of Good record keeping:- Handwriting should be legible All recorded entries should be signed . put the date and time on all documents record should be readable record should be factual record should be accurate and in such a way that the meaning is clear do not alter or destroy in a record without being authorized maintain confidentially of the documents ,follow rules governing confidentiality in respect of the supply and use data for secondary purposes Knows how to use available information systems and tools . Assess the standard of record keeping and communication
- 12. Types of records use in clinical practice A list of records /documents maintained in the ward is given below- Day and night report book Temperature, pulse and respiratory recording book Treatment book /injection book Sponge book Duty roster for the staff Instruction book which the head nurse carries with her when she accompanies the medical officer on his daily ward rounds
- 13. CONT….. Controlled and local purchase drugs accounting book, a separate register is maintained for dangerous drugs . Stock Indent ledger and dispatch index ledger registers Despatch book Inventories of various stores items held in charge of the nurse Breakage book Memo book or medical officer call book specially for the CMO in case his attention is required in the ward outside normal working hours Telephone message book specially meant for receiving laboratory results of serious patients urgently.
- 14. CONT….. Intake and output chart record Demand books for various stores example medical stores, dry and wet dispensary ,quarter master stores and Red cross stores . Out pass book for male wards Urine test report and weight records specially for medical cases ESR and weight record register for tuberculosis patients Complaint book for maintenance and repairs
- 15. CONT… Suggestion books for officers and officers family ward only Admission and discharge book Scale of hospital diets and extras Standing orders for patients Fire officers Instructions for special radiological examination like intervenous pyelogram , barium meal ,barium enema, cholecystography and so on.
- 16. Characteristics of Good Recording The objectives of the records should be clear and should be able to recognise the pertinent factors like what to record ,when to log,why record, how to file, who will record. The records should be specific and concise to the purpose. there should not be any duplicity There should be enough space to record Record information immediately, the information should be accurate The language used should be legible, simple and understood by the team members
- 17. General guidelines for recording Data and time Timing legibility Permanency correct spelling Signature Accuracy Use specific descriptions
- 18. CONT….. Do not erase or use corrective fluid Sequence Appropriateness Completeness Conciseness Standard terminology legal cautions
- 19. legal aspects of charting…..
- 20. Records available in nursing units Various types of documents maintained in nursing units can be classified under nursing administrative records, personal records, clinical records and miscellaneous record.
- 21. Records available in the nursing office Nursing administrative:-hospital policy manual ,nursing policies, organisation chart nursing procedure manual ,etc Personal:- general: cumulative records ,performance, personal files etc Personnel duty: related records: duty roster, duty list roll call registers, allocation and leave forms etc. Patients: hospital report, census book ,etc.
- 22. Reports Introduction: A report is a system of communication aimed at transferring essential information necessary for safe and holistic patient care. A report consists of oral or written exchanges of information shared between members in the health team in a number of ways .
- 23. Definition According to petters and Perry , report are oral or written exchanges of information shared between care giver in number of ways. According to Barbara Cozier, Reports in an oral or written account by one number to others ,in the health team ,for instances nurse always reports on clients at the end of a hospital work shift.
- 24. Objective of reports It presents factual information to the management and there by search as a means of communication it provides valuable clinical information of patients that can be used for further reference it provides necessary information to the department ,clients and general public at large.
- 25. Purposes of reports To communicate progress of the patient’s health status to all nurses in different shifts to prepare staff members for their days work to provide quality and continuity of care from one shift to the next to show the kind and amount of service rendered over a specific period to act as an aid in studying health conditions To act as an aid in planning
- 26. Types of reporting The types of reporting are as follows- Change of shift report It is a report by the nurses on one shift to nurses of the next shift change. It provides continuity of care of the patient to the nurses by providing a quick description of patient health status and details of care .the point that should be kept in mind while reporting are- The information should be accurate, factual and organised avoid negativism and subjectivity while reporting Focus on abnormal findings and variations from routine or the norm
- 27. Types of change of shift report Written report Verbal report Bed side report Telephone report Telephone orders Transfer report Incident reports or occurrence reports Conferring
- 28. Intradivisional report Among nursing staff Between nursing sisters and staff members Between nursing sister and matron Between nursing sister and doctors
- 29. Intra departmental report It is a communication between two departments the reports are sent from one department to another or vice versa for example in the hospital the head of the nursing department send patients report and the staff report of the medical superintendent. such report include report book indicating reports of the patients, VIP and acute patients ,any event or disaster mishappening , accidents ,complaints, staff performance reports etc
- 30. Advantage of maintenance of records and reports Guides sound decision making Acts as effective channel of communication Serves as a tool for performance evaluation promotes accountability and efficiency serves as legal documents Provides data for research and vital statistics.
- 31. Thank you