DOCUMENTATION AND REPORT WRITING ........ppt

Leadership and Management

1. DOCUMENTATION AND
REPORTWRITING
FRED PAUNDI
11/07/2024

2. “Everything you say should be
true, but not everything true
should be said.”
Voltaire

3. Introduction
Effectivecommunicationamonghealth
professionalsisvitaltothequalityofclient
care.
Healthpersonnelcommunicatethrough
variouswayssuchasrecords,reports,
presentations,journals.
Writingreportsisaneverydaythinginthe
hospitalsetup.

4. Innursing,weusetheoralorwrittenreports
whichgiveinformationonaparticularpatient.
Reportisasummaryoffindingsand
recommendationsaboutparticularmatteror
problem.
Reportguidesauthoritiesanditfacilitates
timelydecisionsandfollowups.

5. Definitions
Documentation/Recording/Charting
Theprocessofmakinganentryonaclient
record.
Documentation
-Thisisanywrittenorelectronically
generatedinformationaboutaclientthat
describesthecareorservicetotheclient.

6. Report
Thisisaself-explanatorystatementoffacts
relatingtospecificsubjectandservesthe
purposeofprovidinginformationfordecision
makingandfollowupactions.
Itisasystematicpresentationofascertained
factsaboutaspecificevent/subject

7. -Oral,writtenorcomputerbased
communicationofclient’sdatawiththe
purposeofinformingothers(Taylor,1989).
-Oralorwrittenexchangesofinformation
sharedbetweencaregiversorworkersina
numberofwords(Basavanthappa,2003).

8. Recording:
Writtendocumentationofallpertinent
interventionsoftheclient:assessing,
diagnosis,planning,implementingand
evaluating(Tayloretal.,1998).

9. Record:
Permanentwrittenorcomputerbased
communicationofdatawiththepurposeof
informingothers(Basavanthappa,2003).
Aclinicalrecordalsocalledachartorclient
recordisaformal,legaldocumentthat
providesevidenceofaclient’scare.

10. Reason for Documentation
1.Tofacilitatecommunication:Through
documentation,nursescommunicatetoother
nursesandcareproviderstheirassessments
aboutthestatusofclients,andnursing
interventionsthatarecarriedout.
2.Documentationofthisinformation
increasesthelikelihoodthattheclientwill
receiveconsistentandinformedcareor
service.

11. 3.TopromotegoodNursingcare-
Documentationencouragesnursestoassess
clientprogressanddeterminewhich
interventionsareeffectiveandineffective,
andidentifyanddocumentchangestothe
planofcareasneeded.

12. 4.Tomeetprofessionalandlegalstandards-
Documentationisavaluablemethodfor
demonstratingthat,withinthenurse-client
relationship,thenursehasappliednursing
knowledge,skillsandjudgmentaccordingto
professionalstandards.

13. 5.Thenurse’sdocumentationmaybeused
asevidenceinlegalproceedingsthrough
professionalregulatorybodies.E.g.inacourt
oflaw,theclient’shealthrecordservesas
thelegalrecordofthecareorservice
provided.

14. MANAGEMENT REPORTS CAN
FALL INTO 3 CATEGORIES
1.Persuasive
Herethewriterhastheobjectiveof
influencingorpersuadingthereadertotake
somespecificaction.
Tobeeffective,thereportmustshowthatthe
advicegiveniscorrectandshowthatitis
superiortoanyotheralternativecourseof
action.

15. 2.Informative
-Inthistypeyouaregivingnewfactstothe
reader.
Youalsowanttorelatecauseandeffectsof
factsreviewedbyinvestigations.

16. 3.Confirmative
-Inthisreport,youplacesomeimportant
factsonrecord.

17. PRINCIPLES OF REPORT
WRITING
Whenyouarewritingareport,bearinmind
thatthereaderofthatreportisthemost
importantperson.
Thereportshouldconveythemessagethat
isintendedfor.
Thereare3mainprinciplesinwritingthe
report.

18. 1.Brevity
Thereportshouldbeasbriefaspossible.It
shouldberelevantbynotincludingmaterial
thatdoesnotcontributetothepoints
requiredtobemadetoachieveaction.
E.g.Ifyouarewritingonapatientona
particularward,donotreportthatyoufound
thepatientsleeping,snoringetc.

19. Donotrepeatindetailwhatthereader
alreadyknows,exceptconfirmfigures
relativetothereport.
Youusemaximumideasandwordsto
expresswhatyoumean.

20. 2.Clarity
-Thereshouldbenodoubtaboutthe
meaningofyourwordstheyintendtomean.
Youavoidambiguity.
Onlyusejargonandabbreviationsifyou
knowthatyourreaderswillunderstandthe
meaningofthosewords.

21. 3.Accuracy
-Distinguishmattersoffactsfrom
assumptions.
Whenyouusefigures,makesurethatthey
arecompleteandarithmeticallycorrect.


22. Therefore, a mix up in any factual information
that you write can adversely affect the reader
who may have a bias against your report
even though the rest of it may be totally
accurate.

23. Format for report writing
1.Introduction
Thisshouldbeshort.Itshouldstatebriefly
thetermofreference,purposeandanyother
matterswhichwillplacethereportinits
settingforthereader.
2.Mainbody
-Thiscanbedividedintoparagraphs

24. 3.Conclusion
Thisisthesummaryofthetextinthemain
body.
Thisiswhereyouaregoingtoincludethe
findingsandreferencesofthosefindings.
Itshouldnotincludethingsfromthetext.

25. 4.Recommendations
-Thisshouldarisefromtheconclusionsor
resultsofyourwork.
Somepeopleprefertowriteasummaryin
whichtheygiveabriefreportcoveredinthe
maintextandtheachievements.
Thisenablesthereadertogiveaquick
answerratherthanwritingthewholereport.
5.References-Thisiswrittenbehindthe
reportandshouldbeinalphabeticalorder.

26. 5. References
-This is written behind the report and should
be in alphabetical order.

27. TYPES OF REPORTS
WrittenreportWritteninformationisless
likelytobemisinterpreted.
Itcanalsobeconveyedgraphicallysothat
factsareregisteredquicklyandcomparisons
made.

28. Informationthatcanbeincludedinthe
reportsare:
-Generalconditionofpatient
-Diagnosis
-Vitalsignobservations
-Anyaccidentsustainedbythepatient.

29. -Reportofactiontakenasaresultof
patient’scondition.
-Informationaboutthetreatmentpatientis
receiving.
-Instructionsaboutanyspecialobservations
tobemadeortreatmenttobegiven.-
Informationgiventothepatientconcerning
hisillness.

30. Verbalreports
Theverbalreportsarebasedonthe
informationthatonegetsfromobservation
andwrittenrecordssuchascharts,nursing
records,medicalnotesandthereportsof
medicalresultsofinvestigations.

31. Verbalreportsinclude:
-Reportswhenroundsaredone.
-Whenindividualpatientsarevisited.

32. Theseare;
-Givenroutinelyinanemergency.
-Giventothenursingstaffatthebeginning
oftheirshifts.
-Giventoindividualstaffsastheycontinue
theirwork.

33. Thesearemoreflexiblebecausepersonto
personcontactenablesadjustmentstobe
madetothereportinaccordancetothe
needsoftherecipient.

34. Advantages
-Persongivingthereportcannotethe
reactionoftherecipient.
-Canexplaintocertainunclearstatements.
-Shecanput/layemphasisoncertainpoints
shethinksnecessary.
-Whengivingreport,therecipientcanalso
askquestions.

35. 24-hourreport/mid-nightreturns
Thisinformationaboutthewardsituationis
summarizedwhenitisrequiredbythesenior
management.
Eachwardmanagerduringspanofdutyis
responsibleforcontributingtowardsthis
report.

36. Therefore,thenightsisteralsowritesher
ownreportandsendsittothenursing
manageratthebeginningofeachshift.

37. Theinformationthatcanbeincludedinthis
reportis:
Availabilityofbeds,Numberofpatients.
Transferred,Discharged,Deaths,Absconded
andLodgers.

38. Writtenreportsarealsodoneon:
-Newpatients/Admissions
-PatientsgoingforOperatingTheatre.
-Patientspreparedforinvestigations.
-Seriouslyillpatients.
-Detailsofpatientswhohavediedsincethe
lastreport

39. Why is it important to keep
accurate client records?
1.Ultimately,accurateclientrecords
enhancetheagency’sabilitytointervene
effectivelyonbehalfoftheclienttomeet
his/herneeds.

40. 2.Recordsare,aboveall,adocumentation
ofeligibilityandserviceprovision.Anagency
shouldbeabletoturntoitsrecordsand
identifywhohasbeenserved,whytheywere
eligibletoreceiveservices,whatservices
wereprovided,andtheoutcomesofthose
services.

41. 3.Record-keepingisalsoessentialtoidentify
the“bestpractices”oftheinstitutionandto
learnaboutwhichservicesareworkingand
whichonesarenot.
4.Clientrecordsassurecontinuityofservice
ifproperlymaintainedandroutinelyupdated.

42. 5.Theexistenceofanaccurateclientrecord
canpreventduplicationofeffort,savetime,
andresultinmoreeffectiveprovisionof
servicestotheindividualclient.
6.Clientrecordsprovidethesupervisorwith
atoolforkeepingtrackofworkeractivityand
forprovidingcaseguidance.

43. 7.Recordreviewisalsoameansof
assessingthekindandqualityofservices
beingprovided.Accurateclientrecordswill
facilitateon-goingservicedeliveryand
improveclientinterventions.

44. 8.Forauditingpurposes.Anauditisareview
ofrecords.Client’srecordsareauditedfor
qualityassurance.
9.Research,theinformationcontainedina
recordcanbeavaluablesourceofdatafor
research.
10.Education,client’srecordscanbeused
aseducationaltoolsformedicalandstudents
ingeneral.

45. 11.Legalpurposes,clientsrecordisalegal
documentandisadmissibleincourtas
evidence.
12.HealthCareAnalysis–informationfrom
recordsmayassisthealthcareinstitutionsfor
planningofresources,utilizationof
resources,SWOTincaredelivery.

46. 13.Recordkeepingcommunicateslegally
relevantinformationaboutpatientstatus,
medicalcare,andnursingcareregimens,
andcompliancewithestablishedstandards
ofcare.

47. Accuratechartingservesadualfunction;
a)Itprovidespertinentandusefuldataabout
thepatient’scondition,togetherwiththe
medicalandnursingactivitiesemployedin
hisorhercare.
b)Arecordofadherencetoaccepted
standardsofcareismaintained.

48. Conferring
Toconferistoconsultanotherpersonor
personsforadvice,information,ideas,or
instructions.
Nursesconferwithcolleaguesandother
healthprofessionalsaboutsomeaspectof
clientcarervalidatedataneededtoplan
nursingcare.

49. Twowaysnursesshareinformationare
throughthenursingcareconferenceand
nursingrounds.
1.Nursingcareconferences
Isameetingofagroupofnursestodiscuss
possiblesolutionstocertainproblemsofa
client.

50. Thenursingcareconferenceallowseach
nurseanopportunitytoofferanopinion
aboutpossiblesolutionstotheproblem.

51. NursingRounds
Areproceduresinwhichagroupofnurses
visitsselectedclientsateachclient’sbedside
to;
-Obtaininformationthatwillhelpplan
nursingcare.
-Provideclientstheopportunitytodiscuss
theircare.

52. -Evaluatethenursingcaretheclienthas
received.
Duringrounds,thenurseassignedtothe
clientprovidesabriefsummaryoftheclient’s
nursingneedsandtheinterventionsbeing
implemented.

53. Nursingroundsofferadvantagetoboth
clientsandnurses:clientscanparticipatein
thediscussions,andnursescanseethe
clientandtheequipmentbeingused.
Medicaltermsshouldbeavoidedduringthe
round;uselanguagetheclientscan
understand.

54. Types of Records and Reports Kept in
Nursing Training Institutions
StudentsRecordsandReports
EvaluationManualRecord
-Recordonhowastudenthasbeen
performingwhileontheclinicalarea.
Withoutarecordofevaluationmanual,a
studentcannotbeallowedtositfor
examinations..

55. HealthFile
-Healthofthestudentisrecorded(medical
reportsandsickreports)inthisfileandthis
helpstheschooltoknowthehealthstatusof
astudentandwhatspecialneedsthat
studentmayrequire.
Thisisaconfidentialfilethatshouldnotbe
accessedbyotherfellowstudents

56. ConfidentialReport
-Everycorrespondenceforthestudentsuch
asacademicperformance,behaviour,
discipline,achievementsarekeptinthisfile.
Only,authorizedpersonsshouldonly
accessthisdocument.

57. AcademicFileReport
-Students’progressinschoolisrecorded
fromthetimethisstudententeredthe
nursingschooluptothetimeofcompletion.
Schoolperformanceandnumberofsubjects
takenarerecorded.
Thisisimportantforfuturereferenceincase
oftranscriptwhenaformerstudentwants
reference.

58. ConfidentialReportsforstaff
-TheofficeoftheEducationManagerkeeps
thestaffconfidentialrecords.
Eachmemberofstaffhasaconfidentialfile
whereconfidentialreportsaredocumented.
Inthisreport,thesuperioratanursing
schooldocumentsthemembersofstaff’s
performanceandbehaviourinrelationtohis
orherjobdescription.

59. Thehealthrecords(sickfiles)ofstaffare
alsokeptinconfidentialfiles.
Whenamemberofstaffneedsatransferto
anotherplaceorreference,theconfidential
reportshavetobereferredto.

60. PerformanceAssessment(StaffAppraisals)
Reports
-Methodusedtoassesstheemployee’s
potentialsandperformancetomakesure
thattheyarebeingmaximized.
ItistheresponsibilityoftheEducation
Managertoevaluatethestaff.

61. Supervisorsareexpectedtocommunicateto
thoseinhigherauthorityinformationabout
theiremployeesthatshouldbeusedasbasis
foraction.
Itmaybewrittenorunwrittenreport.Butnow
itisveryimportantandalwaysbettertouse
morecarefullyplanned,organizedwritten
reportsforevaluationofthestrengthsand
weaknessesoftheirsubordinates.

62. MonitoringandEvaluationRecordsand
Reports
-Thesearespecialtoolsusedbytraining
institutionstoassessiftheplannedactivities
oftheinstitutionforaspecificperiodoftime
arebeingachieved.
Forinstance,theinstitutioncanplanthatin
thefollowingyeartheschoolshallhavea
100%passrate.

63. Thisplanshallbemonitoredthrough
continuousassessmenttestsgivento
students.
Thosethatarenotperformingwellare
helpedormaybedeferredsothattheycan
catchup.

64. Thefacultywillbehavinganongoing
evaluationofthestudent’sprogressandthe
finalevaluationisdoneattheendofthefinal
yearwhenstudentswritetheirfinalexams
andresultsreleasedbyNMCZ.

65. GraduationCeremonyRecordsandReports
-TrainingInstitutionskeeprecordsof
graduationceremoniesandthenumberof
studentswhograduatedinthatyear.
Alistofthosewhograduatedwithhonoursis
alsokept.

66. Theserecordsindicatethepasslistandthat
offailuresifany,theinstitutionreferstosuch
typeofrecordsandimproveonthedemerits
encounteredinthepreviousyears.
Theserecordsalsohelptheschooltoplan
aheadforthenextgraduationceremony.

67. StaffMeetingRecords
Arecordofminutesiskeptforallthestaff
meetingsthattheinstitutionholds.
Inthemeeting,variousissuesarediscussed
onhowtoruntheinstitutionandhowtolook
afterthestudent’swelfare.
Membersofstaffshareideasandplan
togetherhowbesttheschoolcanberun.

68. RecruitmentandSelectionRecords
-Recordsarekeptforrecruitedandselected
candidatesinthetraininginstitution.
Thoseselectedarewrittentoandthe
requirementsindicatedontheiracceptance
letters.
Thosenotselectedarealsowrittentoand
reasonsfornotbeenselectedare
documented.

69. Informationisusedforplanningintermsof
thenumberofstudentswhowererecruited
andhowmuchtheypaidintheprevious
years.

70. InventoryRecords
-Thetraininginstitutionskeepinventoryof
schoolfurnituresuchastables,chairs,and
desksandalsofridges,electronicequipment
likecomputersandalltheinstitutional
property.
Inventorysavesasabasisforaccountability
foralltheinstitutionalpropertyandthosethat
needtobereplaced

71. Each office should have a record of school
property e.g. assets register.

72. DisciplinaryRecords
-Minutesofthedisciplinarycommitteefor
studentswhoarefoundwantingiskeptinthe
disciplinaryfiles.
Thedecisionsmadeaftersuchameetingare
recordedandkeptinconfidenceforfuture
reference.

73. Disciplinaryrecordsandreportsarean
institutionalpropertythatcanbeusedas
referenceincaseofalegalsuitbya
disciplinedstudent.

74. WardAffairsRecordsandReports
-Thetraininginstitutionsarenotanisland;
theycoordinatetheiractivitieswithclinical
staff.
ThestaffandWardin-chargesusuallyhave
wardaffairsmeetingsandplanhowbestthe
studentsaretobelookedafterand
supervisedwhentheyareontheclinical
area.

75. Theneedsofthestudentsarediscussedand
theshortfallsnoted.
Minutesofwardaffairsmeetingsarekeptas
evidenceofthemeetinghavingtakenplace.
Thisrecordactsalsoasasourceof
referenceforfutureusewhenneedarises.

76. FinanceandBudgetingRecords
-Traininginstitutionskeeparecordof
financeandbudgetingminutes.
Acommitteeisformulatedthatlooksintothe
financesoftheschool.
Arecordoftheinstitutionalexpenditureis
keptforinternalandexternalauditorswhen
theycometoaudittheschoolaccounts.

77. Withoutrecordsoffinancialexpenditureitwill
bedifficulttoknowhowthefundswereused
andcouldnotbeaccountedforduring
auditing.

78. EducationCommitteeRecords
-Theeducationcommitteeholdsmeetings
andwhatisdiscussedisrecodedandfiled.
Thiscommitteecomprisesthetutors,
studentrepresentatives,andpersonnelfrom
MinistryofEducationandamemberfromthe
generalpublic.

79. Thecommitteediscussestheeducation
affairsoftheinstitutionandthatofstudents
andarecordofminuteskeptbythe
institutionforreference.

80. RegisterBooks
-Traininginstitutionkeepregistersforallthe
students,theseindicatethenumberoftimes
andhourseachstudentattendedaswellas
thenumberofabsentdaysfromclass.
NMCZofZambiarequiresthatastudent
attendacertainnumberofhourspersubject
befores/hecouldbeallowedtowritethefinal
qualifyingexaminations.

81. The registersalsorecordthe
subjects/coursestaughtandtheteacher
shouldsign.
Itactsasevidencethatthesubjectwas
taught.

82. NominalRegisters
-Whereallthenamesofstudentsare
recordedindicatingtheyearofentryinto
training,andwhencompletedschool,ifthe
studentwasdiscontinuedandreinstated,
datesareindicatedwhenthisstudentwas
discontinuedandorreinstatedintoschool.

83. Thisregisteralsohasarecordofallthe
studentsthatpassedthefinalexaminations
andtheyear.
Italsodocumentsallthosewhofailedthe
finalexaminationsandthestepsthatthe
schooltook.
Nursingschoolskeepthisrecordinorderto
accountforthenumberofstudentsthathave
beentrainedbytheschooltodate.

84. Advantages of Record Keeping
and Report Writing
1.Planningandevaluation
-Planningandevaluationofeducational
programmes.
Indicateplansforthefuturelikeinstrategic
andactionplanning.

85. 2.Communication
-Toolsforcommunicationintheschoolsof
nursingwithinandamongtheinstitutionse.g.
NMCZorMOH,ZUNO,Tutors,theschool
andtheclinicalarea.

86. 3.Reference
-Recordsprovidebaselinedataforstudents
andthestaffreferenceexamplethe
transcripts.
4.Research
-Recordshelpinresearchforimprovement
ofnursingeducatione.g.reviewof
curriculum,performanceofgraduatesetc.

87. 5.ResourceMobilization
-Usefulforresourcemobilizatione.g.data
frominventoryrecordscanhelptoevaluate
theneedforreplacementandrepairofaudio
visualaids(AVAs)andotherschool
equipment.

88. 6.Identifystrengthsandweaknessesof
individualstudents
-Pointouttheneedsofthestudents
(Learningneeds)therebyassistinginthe
learningprocess.

89. 7.Serveaslegaldocumentsincaseof
disciplinaryaction
-Serveasawitnessonbehalfoftheschool
toavoiddisgraceinthecourtsoflawe.g.
somestudentsmayappealtoNMCZtobe
reinstatedincaseofdismissalbasedonpoor
academicperformance,withoutrecordsthe
schoolisboundtolosethecase.

90. 8.Usedinprovidingstudentsmotivation
throughthecooperationandrecognitionof
achievements.
9.Usefulforstaffrecommendationand
promotion.

91. Disadvantages of Record and
Report Writing
1.Recordsandreportscanbeoutdated.
2.Biasnessinwriting.
3.Timeconsumingandcostly.
4.Confidentialitycanbebreachedifrecords
andreportsarenotproperlysecured.
5.Canbegapsinreportingbecauseitisnot
possibletoreportanythingaboutindividuals.
6.Canbeusedagainstthefacultyinthe
courtsoflaw.

92. Thank you for your
attention. Good day