nursing records n reports.pptx records and reports

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1. GOVT. COLLEGE OF NURSING AHMEDABAD SUBJECT : NURSING MANAGEMENT UNIT : X- NURSING INFORMATICS TOPIC : NURSING RECORDS AND REPORTS PREPARED BY: Priyanka A. Tandel S.Y.M.Sc.Nursing Roll No.

2. INTRODUCTION An effective health record shows the extent of the health problems, needs and other factors that affect individuals their ability to provide care and what the family believes. What has been done and what to be done now also can be shown in the records. It also indicates the plans for future visits in order to help the family member to meet the needs.

3. PURPOSES OF RECORDS In terms of patient care: Records are maintained to improve patient care. Records are essential to make immediate nursing diagnosis and nursing interventions. It serves to avoid omission or unnecessary duplication of patients care. It serves as evidence in the event, if legal questions arise. record would enable the patient to claim for insurance or contributory health schemes.

4. Continue.. In terms of Nurses Assurance of quality, quality of nursing care being provided. Records help in continuity of the nursing care. Provides legal protection to the nurse. Records serves as an important pre-requisites for evaluation of nursing care. Records help in research and continuing education of nursing professionals. Recorded observation of patient care provides the basis for clinical research.

5. Continue… In terms of nursing administration. The nursing administrative records are essential to document the type and quality of work assigned and accomplished. Nursing administrative records furnish proof of the type and quality of care rendered to patients. Records also provide evidence of efficiency of individual nurse for administrative and clinical purpose.

6. Continue.. Records strengthens the nursing administrator in event legal questions arises. They serves as an administrative record of personnel performance and staffing needs, for budget preparation and justification, for physical facilities, allocation and utilization, for statistical data for administrative use and evaluation, for estimating equipments and supplies utilization and needs .

7. Types of records: Patient’s clinical records The patients clinical chart is the record which the nursing sister or assistant nursing is most concerned. The common patient records are: Admission history Vital signs chart. Treatment/ medication sheet Intake/output chart. Nursing care plan and progress report of the patient

8. nursing administrative records These records can be maintained at the unit level ad submitted to the Nursing Superintendent. The records can be: Number of nurses on roll in the unit and rotation plan duty roster. Stock register of the unit for medicine, equipments and supplies. Annual confidential reports of the staff nurses. Record of staff development programme including orientation and in-service education programme. Records of performance of staff members.

9. Cumulative or continuing records This is found to be time saving, economical and also it is helpful to review the total history of an individual and evaluate the progress of a long period. (e.g.) child’s record should provide space for newborn, infant and preschool data. The system of using one record for home and clinic services in which home visits are recorded in blue and clinic visit in red ink helps coordinate the services and saves the time.

10. Family records The basic unit of service is the family. All records, which relate to members of family, should be placed in a single family folder. This gives the picture of the total services and helps to give effective, economic service to the family as a whole. Separate record forms may be needed for different types of service such as TB, maternity etc. all such individual records which relate to members of one family should be placed in a single family folder.

11. Nursing Superintendent has to keep certain records readily available. Philosophy, aims and objectives of the hospital. Policies of the hospital for recruitment/ selection and other area. Total number of nurses on the roll. The physical layout of various departments. Confidential record of the nursing personnel. Staff development records. Any disciplinary action record. Record of various committees and meeting, memorandum, notices etc.

12. PRINCIPLES OF RECORD WRITING Nurses should develop their own method of expression and form in record writing. Records should be written clearly, appropriately and legibly. Records should contain facts based on observation, conversation and action. Select relevant facts and the recording should be neat, complete and uniform

13. Continue… Records are valuable legal documents and so it should be handled carefully, and accounted for. Records systems are essential for efficiency and uniformity of services. Records should provide for periodic summary to determine progress and to make future plans. Records should be written immediately after an interview. Records are confidential documents.

14. FILLING OF RECORDS Different systems may be adopted depending on the purposes of the records and on the merits of a system. The records can be arranged Alphabetically Numerically Geographically and With index cards

15. REGISTERS It provides indication of the total volume of service and type of cases seen. Clerical assistance may be needed for this. Registers can be of varied types such as immunization register, clinic attendance register, family planning register, birth register and death register.

16. REPORTS Reports can be compiled daily, weekly, monthly, quarterly and annually. Report summarizes the services of the nurse and/ or the agency. Reports may be in the form of an analysis of some aspect of a service. These are based on records and registers and so it is relevant for the nurses to maintain the records regarding their daily case load, service load and activities. Thus the data can be obtained continuously and for a long period.

17. PURPOSES OF WRITING REPORTS To show 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. As an aid in planning. To interpret the services to the public and to other interested agencies.

18. Continue… In addition to the statistical reports, the nurse should write a narrative report every month which provides as opportunity to present problems for administrative considerations. Maintaining records is time consuming, but they are of definite importance today in the community health practice in solving its health problems.

19. Change of shift reports: Change of shift report is the oldest report in the nursing service and it still is very important. Though it has gone many changes but it still remains essentially a method of transmitting the information about care of patient from one set of workers to another. Reports provide the staff an opportunity to learn salient points about patients that have occurred during the hours of prior to their taking the responsibility of patient care.

20. Continue… There are many formats for such overall reporting. Essential information such as discharge, transfers and admission, immediate pre and post operating patients, critical patients, those receiving important procedures such as B.T. those with complication factors such as bed sores/ isolation, neurotic states etc. Format also provides staffing information such as number of patients of each category, i.e. ICU. Acutely ill, evening and night shift, nursing managers require the same type of information.

21. General periodic reports: Though these general periodic reports are as common as change of shift, but they are often used. E.g. The Nursing Superintendent is accountable to the hospital administrator. Like wise the nursing service director requires similar accountability in the form of written report from the department heads or supervisor who in turn gets it from the head nurses. Head nurses get this report from the staff nurses. These are specialised reports which help in preparing these generalised reports such as summary of nursing hours, distribution and kinds of works etc.

22. Hospital annual reports: A detailed report of the nursing services is included in the hospital annual report. Though it may not be existing so significantly in our country but regulatory or accrediting agency reports are equally important. This body gives the report whether the hospital and nursing section is following the minimum norms to give effective patient care.

23. Factors to be kept in mind while reporting and recording: Accuracy of the records is very significant. Accuracy of records and report is affected from honesty, precision and clarity. Records and reports should have sufficient details but not too extensive to lose the actual point. Objectivity of records is equally important. For e.g. Checking of certain facts and then writing the report will have more objectivity.

24. Continue.. Timeliness and promptness helps in better records and reports. Maintaining the confidentiality of records and reports helps in protecting human rights as nurse have a very important role to play in maintaining the records. Availability of record should be to the patient only in consultation with the doctors.

25. CONCLUSION Records and reports revels the essential aspects of service in such logical order so that the new staff may be able to maintain continuity of service to individuals, families and communities.

26. THANK YOU