Records and reports

Records and reports
its definition, characteristics, principles, types and role of nurse.

1. NURSING RECORDS AND REPORTS PRESENTED BY, Mrs. Rijo Lijo Lecturer.

2. INTRODUCTION Accurate documentation of patient symptoms and observations is critical to proper treatment and recovery. Entries written in a patient’s medical record are legal, permanent documents. If documentation is poorly or inaccurately entered into a medical record, the patient may receive improper or potentially harmful care. Physicians and other health care providers use what you document as fact in a resident medical record, to plan, implement, and evaluate the patient’s course of treatment.

3. DEFINITION RECORD “Record is written or computer based used for specific purposes in any form. The process of making an entry on a client’s record is called recording, charting, or documenting.” Jogindra Vati .

4. “ Record are formal legal, administrative tools that permanently document information relevant to direct and indirect patient care”.

5. REPORT “ Report is a oral, written, or computer based communication intended to convey information to others.” Jogindra Vati .

6. “ A report is a system of communication aimed at transferring essential information necessary for safe and holistic patient care.”

7. OBJECTIVES OF HOSPITAL RECORDS To review patient care, take appropriate clinical decisions and to develop treatment plans. To provide an archival and legally acceptable record. To provide material for researchers. To act as a source of information for health administrators.

8. To enables for hospital auditing. To carry out the things in right possible manner. For statistical purposes. To use for teaching and diagnostic purposes. To use for legal purposes.  

9. PURPOSES OF MEDICAL RECORDS TO PATIENTS To improve the patient care. To serve to document clinical case history. It serves to avoid omission or repetition.

10. Assists in continuity of care. Its serves as evidences in medico – legal cases. It supplies necessary information to institute an employees.

11. TO THE HOSPITAL To document the type and quality of work. To furnish proof of type and quality of care. To protect hospital in legal situations. To evaluate proficiency of staff. To help in future programme planning.

12. PURPOSES OF PATIENT RECORDS Communication. Planning client care. Auditing health agencies. Statistical and research. Education.

13. Reimbursement. Legal documentation. Health care analysis and evaluation.

14. TYPES OF DOCUMENTATION SYSTEM: Source – oriented records. Problem – oriented records.

15. TYPES OF CHARTING OR FORMATS OF RECORDING: NARRATIVE CHARTING. SOAP CHARTING. PIE CHARTING. FOCUS CHARTING.

16. VALUE OF NURSE CLINICAL RECORDS To provide baseline data for further plan of action and to evaluate the care given. For diagnostic and treatment : Nursing records e.g. temperature graphic record, blood pressure record intake /output records etc can be used for diagnostic purposes.

17. To evaluate the work load: this will help for calculation of manpower required in that particular setting. To evaluate the quality of care. To scientific and research purposes. For legal purposes.

18. FUNCTIONS OF RECORDS Helping to improve accountability. Showing how decisions related to patient care are made. Supporting the delivery of services. Supporting effective clinical judgments and decisions.

19. Supporting patient care and communications. Making continuity of care easier. Providing documentary evidence of services delivered. Promoting better communications and sharing of information between members of the multi professional health care team.

20. Helping to identify risks, and enabling early detection of complications. Supporting clinical audit research allocation of resources and performance planning. Helping to address complaints of legal processes.

21. Records should be punctual and not include unnecessary abbreviations, Jargon, meaningless praises or irrelevant speculation. Use professional judgment to decide what is relevant and what should be recorded. Record details of any assessment and review undertaken. Include details of information given about care and treatment. Records should identify any risk or problems that have arisen and show the action taken to deal with them.

22. PRINCIPLES OF GOOD RECORD KEEPING: Handwriting should be legible. All entries to records should be signed put the data and time on all records. Records should be accurate and recorded in such a way that the meaning is clear. Records should be readable.

23. Do not alter or destroy any records with being authorized to do so. Do not falsify records. Be aware of the legal requirements and guidance regarding condentiality of the records. Be aware of the rules governing confidentiality in respect of the supply and use of data for secondary purposes.

24. Follow organizational policy and guidelines when using records for research purposes. Do not disclose the information and should not leave any records, either on paper or on computer screens. Be aware of, and know how to use, the information systems and tools that are available. Ensure the proper use of the system particularly in relation to condentiality .

25. CHARACTERISTICS OF GOOD RECORDING Accuracy. Conciousness . Up to date. Organization. Confidentiality. Objectivity.

26. STEPS FOR DESIGNING THE RECORD Constitute a committee. The members should be head of department, hospital administrator, nursing head, supervisor and nursing staff of operational level. Call a meeting and repeated meetings to seek suggestions and prepare a rough draft of record.

27. Pretest it for its validity. Check the feasibility and utility by conducting a pilot study. Periodically evaluate the record.

28. RECORDS AVAILABLE IN THE NURSING UNIT: Patient record. Assignment record. Census record. Inventories record. Narcotics and medication record.

29. RECORDS AVAILABLE IN THE NURSING OFFICE: Attendance record. Personnel record. Employment record. Evaluation record.

30. REPORT DEFINITION: “Report is oral, written, or computer- based communication intended to convey information to others. These can be formal or informal.” Jogindra Vati .

31. “Reporting is the process of informing the other staff about the patients and of other events.” Jogindra Vati .

32. TYPES OF REPORTING: Change – of – shift report. Telephone report. Telephone orders. Transfer report. Incident reports or occurrence reports.

33. CHARACTERISTICS OF EFFECTIVE REPORTING: Accuracy. Conciousness . Up to date. Organization. Confidentiality. Objectivity.

34. PRINCIPLES OF DATA ENTRY AND MANAGEMENT OR GUIDELINES FOR QUALITY DOCUMENTATION AND REPORTING Accuracy. Completeness. Correctness. Confidentiality. Act. Conciseness. Objectivity. Organization. Timeliness. Legibility.

35. ROLE OF ADMINISTRATOR IN KEEPING RECORDS AND REPORTS The reports and records should be kept under safe custody. No individual’s sheet is separated from the complete record. Records should be kept in place, inaccessible to patients and visitors. No stranger is permitted to read the records.

36. Records are not handed over to the legally and ethically obligated to keep in confidence all the information’s provided in the records. All records to be handled carefully. Careless handling can destroy the records. Protection from loss.

37. Filing should be done according to hospital system such as alphabetically, numerically with index cards and geographically. Assess periodically to determine the use of the record and re-examine for means of simplification. All records are identified with the bio data of the patients such as name, age, ward, bed number, outpatient (OP) number, inpatient (IP) number, diagnosis, etc.

38. Records are never sent out of the hospital without the doctor’s permission. Reference is made by writing separate sheets and sending to the agency that requires them, e.g. reference letter, discharge summaries.

39. REFERENCE Vati . Jogindra . Principles and practice of nursing management and administration. 1 st edition. New Delhi; Jaypee Medical Publication;2013:652 - 655. K. Deepak. A Comprehensive Text book on nursing management. 1 st edition. New Delhi; EMESS Publication;2013: 412.

40. Dr. Kochuthresiamma Thomas. Nursing Management And Administration. Kottayam; Medical work publishers; 2011: 163- 172. Available at doi :   10.19082/5439 .