Records and reports maintained in nursing college

nursing administration

1. RECORDS AND REPORTS MAINTAINED IN NURSING COLLEGE

2. INTRODUCTION Record is a permanent written communication that document information relevant to client’s health care management. Report is the summary of the services of personal or person and of the agency.

3. DEFINITION Barbara cozier: Record is a highly confidential, legal document by means of which physician, nurses, social workers and health team members communicate about client. 2.H.A Godard: Records are administrative devices used to collect and classify information. 3.Sr. Nancy: The patients ethical record is a brief account of the personal and medical history of the patient of diagnostic tests, findings of medical examination, treatment , nursing care daily progression advice and discharge.

4. Reports: 1. Pretters and Perry: Reports are oral or written exchanges of information shared between care givers in number of ways. 2. Barbara Cozier: Report is an oral or written account by one member to others, in the health team, for instances nurse always reports on clients at the end of hospital work shift. 3. Sr. Nancy: Reports are the effective method of communication among the members of the health team. Reports are information about a patient either written or oral.

5. PURPOSE RECORDS: Provides a scope of activities within a department. Serve as legal source of document. Provides a base for short and long term plans. Contributes towards budget preparation. Serves as basis for preserving information for reference purposes. Provides for the evaluation programme. Useful for teaching and research. It also serves for statistical purpose.

6. REPORTS: To illustrate progress in reaching goals. As an aid in studying health condition. As an aid in planning. It helps to coordinate care given by several people. It prevents the clients from having to report information to each health team members. It helps the health personnel to make the best use of their time by avoiding overlapping activities.

7. CHARACTERISTICS 1.ACCURACY : Information should be correct to prevent serious mistakes use of erect spelling and the institution accepted abbreviations and symbols ensure accurate interpretation of information. It should be always complete with accurate signature. Do not use nick names. 2. CONSCIOUSNESS: Use a few words as possible to give the necessary information. 3. THOROUGHNESS: Even a concise record or report must contain complete information.

8. 4. UP TO DATE : Recording should be done on time. A definite time and routine for the reporting makes more efficient management. Delay in the recording can result in serious omissions and delay the work. 5. ORGANIZATION: Communicate all the information in a logical format or order. 6. CONFIDENTIALLY: The information should be confidential. 7. OBJECTIVITY: Presentation of facts and not personal facting to give true picture.

9. PRINCIPLES OF RECORDS AND REPORTS RECORDS: Records should be written clearly, appropriately. Record should contain facts based on observation, conversation and action. Records are valuable legal documents and so it should be handled carefully. Records should be written immediately after an interview. Records are confidential documents.

10. REPORTS: 1.Proper flow of information: Flow of information is a continuous activity. Information may flow upward, downward or side ways within an organization. 2. Proper timing: The very purpose of preparation of report is controlling the unfavorable activities. Hence, the report should be submitted at the required time at any cost. 3.Accurate information: The report contains only accurate information. If wrong information are included in the report, it may lead to take wrong decision.

11. 4. Relevant information: Proper attention should be devoted to include only relevant information in the report.

12. TYPES OF RECORDS AND REPORTS RECORD: 1.Record concerning students. 2. Concerning school staff. 3. General school record. Record concerning students: a) Application forms other reports of recruitment, selection and appointment such as reference , medical reports, school records and result of any tests carried out at that time. b) A record of each student clinical experience.

13. c) A Progress report showing grades and other information. d) Final record giving a summary of instruction, clinical experience, grades and other relevants. e) Health recorded leave class attendances. 2. Record of school staff: In the persons file of each staff members following records are: a) Application form b) Copy of letter appointment ( Posting Order) c) Job description

14. d) Records of staff members: Educational qualification, previous experience, membership in professional societies, professional activities like contribution to journals holding office in association organization, participation in seminars ,conferences. e) Periodic evaluation or progress report. f) Leave recorded. g) Health recorded.

15. 3. General school record: The philosophy, purpose, curriculum of the school. Written policies of the school. Statements of budgets proposals and allotment. Letters of agreement with affiliating agencies. Copy of school prospectus. Inventions of stock. Examination recorded.

16. REPORT: 1.Factual data related to students, staff. Clinical facilities, physical facilities, administration and the curriculum. 2. Developments in the school programme since the report. 3. Proposal and plans for future development.

17. IMPORTANCE OF RECORDS AND REPORTS For individual and family: Records serve to document the history of the client. Records assist in the continuity of cure. Records serve as an evidence to support the legal questions that arise. Records serve to recognise the health needs and can be used as a reservoir and teaching tool.

18. For the doctor: Records serve as guide for diagnosis, treatment, follw -up and evaluation of service. Records help self-evaluation of medical practice. Records protect the doctor in case of legal issue. Records may be used for teaching and research.

19. For the nurse: The record provides with documentation of services rendered. Records provide data essential for planning and evaluation of services for future improvement. Records serve as a guide for the professional growth. Records indicate plans for the future.

20. For Authority: Records provide the management with statistical information necessary for decision in regard to utilization of resources, planning for administrative control and future references.

21. REPORTS: 1.Change of shift reports: Provide any essentially background information about client but do not review all routine care procedure. Identify clients nursing diagnosis and other related causes but do not review all biographical information on case sheets. Evaluate results of nursing or medical care. Do not simply describe results as good or poor.

22. 2. Transfer reports : Patients will frequently be transferred from one unit to another to receive different levels of care. Clients name, age, primary doctor and medical diagnosis. Current health status- Physical and psychological. Needs for any special equipment etc.

23. 3. Incident Reports: Nurses usually become involved in client related incidents at some point in their careers. The nurse does not interpret or attempt to explain the cause of the incident. The nurse describes in concise what happened in specifically objective terms etc. The nurse should never make pro to copy of incident report.

24. 4. Legal reports : Incident reports and on accidents, mistakes and complaints are legal in nature. There are times of when hospital is exoticized for what is claimed to be negligence or poor care because of a condition that resulted in discomfort.