Records & Reports-shanthi.ppt
- 1. PATIENT RECORD SYSTEM, NURSING RECORDS & REPORTS Presented by: P. Santhi, M.Sc.(N) II Year.
- 2. INTRODUCTION We are living in an era of ‘consumerism’, ‘accountability’, and ‘quality assurance’. Today the nurses are accountable to the clients for the care provided as providers of services. The service of a nurse will be meaningful only when they are properly recorded and maintained. Record is an account of something, written to perpetuate knowledge of events. Records and reports are indispensable aids to all who are responsible for giving the best possible service to individuals, families and to the community.
- 3. Terminologies Record: It is a written communication that permanently documents information relevant to a client’s health care management. It is a continuing account of the client’s health care needs. Report: It is oral or written information about a patient by one member of the health team to another. Kardex: Kardex, a portable “flip-over” file or note book is kept at the nurse’ station. Most Kardex forms have an activity and treatment section and a nursing care plan section that organize information for quick reference as nurses give change-of-shift reports or make walking rounds.
- 4. DEFINITION A client’s record or chart is a confidential, permanent legal documentation of information relevant to a client’s health care. Medical record is a clinical, scientific, administrative and legal document relating to patient care in which are recorded sufficient data written in the sequence of events to justify diagnosis and warrant treatment and end results. - McGibony Medical records is defined simply as a systematic documentation of a patient’s personal and social data, history of his or her ailment, clinical findings, investigations, diagnosis, treatment given and an account of follow up and final outcome.
- 5. PATIENT RECORD SYSTEM This is the method of collecting data from the patient and recording. This includes: Interview Process recording Voice recording
- 6. INTERVIEW Interview is a meting at which information is obtained from a person. (Webster) Interview is professional goal directed interaction between two people. The essential elements of interview are a face to face meeting and conversation between individuals attempting to arrive at a solution of the same problem. A conversation with a specific purpose. (Erickson)
- 7. Techniques of Interview Observing Listening Restating Validating Reflecting Providing information Clarifying Paraphrasing Pinpointing Linking Focusing Sharing Summarizing Questioning
- 8. Attitude of interviewer Acceptance of patient. Avoid false reassurance. Build strengths. Reinforce Avoid judgement Avoid saying “yes I understand you.” Look for attainable goals. Allow freedom of expression Win the patient’s confidence Try to make the interview helpful. Help to identify his problem Close the interview carefully. Stop at the fixed time
- 9. PROCESS RECORDING The interaction or interview is recorded by the nurse by using various communication techniques. During conversation she draws inference. Recording of the interview is called process recording, which includes participants, conversation and inference.
- 10. VOICE SYSTEM Voice recognition, where computer users talk to a computer, or health care providers use this to dictate the patient conditions. Individual users train their PCs to recognize their voices and are able to dictate documents and e-mails and direct their computers to perform specific activities upon voice command.
- 11. VALUES OF RECORDS PATIENT PHYSICIAN HEALTH CARE INSTITUTION RESEARCH TEAM NATIONAL HEALTH AGENCIES INTERNATIONAL HEALTH ORGANIZATIONS
- 12. ADVANTAGES OF RECORDS KEEPING Help in sound decision making Effective channel of internal control Facilitate evaluation of corporate performance Promotes efficiency of operations Fulfills statutory requirement Futuristic approach
- 13. PRINCIPLES OF RECORD WRITING & MAINTAINING own method of writing written clearly and legibly contain true facts Printed records complete and accurate information No blank space filed in serial number and should be properly arranged continuity should be maintained provide periodic summary written immediately after our service brief and neat kept as confidential handled properly, carefully and safely new or revise old forms
- 14. METHOD OF RECORDING Narrative documentation Problem oriented Medical Record Focus charting Source records Charting by exception Case management plan and critical pathways
- 15. Narrative documentation Advantage: It allows the nurses to describe a condition, situation or response in their own terms as they understand it. Disadvantage: tendency to repetition of information time consuming the reader need to sort the information to locate the desired data.
- 16. Problem oriented Medical Record The problem oriented medical record (POMR) is designed by Dr. Lawrence Weed several decades ago, is a method of documentation that places emphasis on the client’s problems. Data are organized by problem or diagnosis. This has the following major sections: database problem list nursing care plan progress notes
- 17. Problem list: After data are analyzed, problems are identified and a single list is made. The problem list includes the client’s physiological, psychological, social, cultural, spiritual, developmental and environmental needs. The problems are listed in chronological order and filed in the front of the client’s record to serve as an organizing guide for client’s care. New problems are added as they are identified. PROBLEM No.DATE NOTEDACTIVE PROBLEM(Present)INACTIVE PROBLEM(past)
- 18. PROBLEM LIST PROBLEM No. DATE NOTED ACTIVE PROBLEM(Prese nt) INACTIVE PROBLEM(p ast)
- 19. PROGRESS NOTES Health care team members monitor and record the progress of a client’s problems which can be expressed in various formats. SOAP Charting: S- Subjective data (verbalizations of the client) O- Objective data (which are measured and observed) A- Assessment (diagnosis based on the data) P- Plan (what the caregiver plans to do)
- 21. SOAPIE charting is used in some institutions which includes; o I – Intervention o E – Evaluation PIE format: o P – Problem o I – Intervention o E – Evaluation
- 22. PIE
- 23. Focus charting It includes use of DAR notes, which include D – Data (both subjective and objective) A – Action or nursing intervention R – Response of the client (evaluation of effectiveness)
- 24. Focus charting Advantage Disadvantage Ease of charting with Data, Action and Response Components of DAR can be cited alone or out of sequence. Many nurses have difficulty in documentation by separating the DAR categories.
- 25. Advantages of the POMR It improves patient care It enumerates the patient’s problem as single entities, listing the diagnostic and therapeutic steps for each problem, indicating the progress of each problem and thereby presents a total picture of each patient. It brings all patient problems into focus It defines problems and utilizes knowledge more effectively. It assures better communication It permits any member of a health care team to review a record It standardizes data in a uniform manner. It allows physicians to logically direct the health care team. It enhances the field of epidemiology. It facilitates general health service planning. It helps for student learning, research activities and monitor the progress made on the patient. It act as a legal document
- 26. Source Records In a source record the client’s chart is organized so that each discipline (nursing, medicine, social work or respiratory therapy) has a separate section in which to record data. Advantage: easy to locate the proper section of the record in which to make entries. Disadvantage: the details about a specific problem may be distributed throughout the record.
- 27. Charting by exception This is an approach that is used to eliminate redundancy, ensure concise documentation of routine care, emphasize abnormal findings, and identify trends in clinical care. It is a shorthand method for documenting normal findings and routine care based on clearly defined standards of practice and predetermined criteria for nursing assessments and interventions.
- 29. Case management plan and critical pathways The case management model of delivering care incorporates a multidisciplinary approach to documenting client care. The critical pathways are multidisciplinary care plans that include client problems, key interventions, and expected outcomes within an established time frame. The use of a computerized charting system allows for integration of the chart by many disciplines.
- 30. Case management plan and critical pathways
- 31. COMMON RECORD KEEPING FORMS Admission Nursing History Forms Flow Sheets and Graphic Records Client Care Summary or Kardex Acuity Records Standardized care plans Critical/ collaborative pathways Progress Notes Discharge and Transfer summary Home Healthcare Documentation Long term care Documentation Computerized documentation
- 32. MECHANISM OF RECORDS MANAGEMENT Filing Filling arrangement File indexing Vertical card indexing Visible card indexing Visible book indexing Loose leaf book indexing Centralized and Decentralized Filing System
- 33. ISSUES AND PROBLEMS Use of Out-dated Forms Shortage of Experience Personnel Lack of Planning of Storage of In-active Records Need of effective handling and processing of records Need of determination of records retention period Transfer of records Need of improving quality of medical records
- 34. RECORDS IN NURSING EDUCATION Types of records: Those concerning with students Those concerning with staff General school/college records
- 35. RECORDS OF PUBLIC HEALTH Cumulative or continuing records. Family records/family folders Registers Reports
- 36. REPORTS It is oral or written information about a patient by one member of the health team to another. The criteria for good report should include: promptness completeness consciousness clarity organization and accuracy Types Oral Written
- 37. Different types of oral reports Reports between the head nurse and her assistant Reports between nurses who are assigned to bedside care on change of shift Reports of staff members to the in-charge nurse Nurse in-charge report to bedside nurses: Report of the head nurse to the administrative supervisor Reports to Clinical Instructor Report of the head nurse to the director of nursing or her assistant Reports of the nurse in-charge to the physician Reports on policy changes Telephone/telemedicine reports Reports to family members and significant others
- 38. WRITTEN REPORTS Reports are written when the information is to be used by several people or is more or less of permanent value. Features: should show an awareness of time and thinking. It should concentrate on the past, present and future state of the patient or the event. Description and conclusion of action that influence further planning and decision making are necessary. Clear, unbiased observation of persons, relationship and events is needed to write a meaningful report.
- 39. Types of written reports Day, evening and night reports Census report Interdepartmental reports Inter agency reports:/ Transfer and Discharge Reports 24 hours report Incident Reports/Accident report Department reports Labour hours report
- 40. conclusion Keeping of records and reports is a necessary activity in every administrative and educational organization. The patient’s clinical record is the most important administrative record for which head nurse is responsible. Reports also serve as source of reference and it also has legal values. The nurse administrator should see her role in maintaining records and reports in clinical practice, nursing education and public health.