records and reports.pptx

management

1. RECORDS AND RE P OR T S

2. Principles of documentation 1. DATE & TIME Document date and time of each recording. Record time in conventional manner (E.g. 9am, 6pm etc) or according to the 24 hour clock (military clock) Avoid recording in advance. 2. Legibility Entries must be legible and easy to read. Writing must be clear. Very important in recording numbers and medical terms

3. Principles of documentation 3. Correct Spelling Correct spelling is essential for accuracy. 4. Permanence Entries should be done in dark ink. It helps to identify changes and allows duplication 5 . Acc e p t ed T ermin o l og y Use commonly accepted abbreviations, symbols and terms that are specified by the agency

4. Principles of documentation 6. Factual Descriptive objective information about what nurse sees, hears, feels and smells. Use of inference without supporting data is not acceptable. Vague terms like appear, seem or apparently is not accepted. Include objective signs of problems. Subjective data is documented in client ’ s exact words within quotation marks.

5. Principles of documentation 7. Accurate Use of exact measurement establishes accuracy.eg. Intake 450ml of water than writing adequate amount of water. Clients name and identifying information is written on each page. Before making any entry in the chart makes sure that it is correct. Chart only your observations and actions to be accountable. If any mistakes occur while recording, draw a line through it and write above or next to original entry with your initials or name. Do not erase, blot or use correction fluids.

6. Principles of documentation 8. App r opri a ten e ss Record information's pertaining to the client health problems& care only.

7. Principles of documentation 9. Completeness Document all necessary information's. It should give a clear picture of what took place Complete pertinent assessment data such as vital signs, wound drainage, client complaints, which was notified and what interventions are carried out are recorded.

8. Principles of documentation 10. Current Timely entries are must Keeping record at bed side may facilitate immediate documentation 11. CONCISENESS (BRIEVITY)Recording need to be brief as well as complete to save time in communication Client ’ s name and the word client can be omitted E g. “ perspiring profusely. Respiration shallow. 28/mt ” Use accepted abbreviations18. 13

9. Principles of documentation 12. ORGANIZED Information should have logical manner. E g. description of pain, nurses assessment and interventions and the client response This helps in preventing any omission of information. Easy to read. 13. SIGNATURE Each recording is signed by the nurse Signature includes the name and the title in computerized charting nurse will have his or her own code.

10. Principles of documentation 14. Confidentiality All the client ’ s record are confidential files The information in the chart is personal as well as legal. Record shouldn't be copied without the permission of the client .Nurse should not allow any outsiders to verify the client record.

11. Types of documentation: RECORD Record is a permanent written communication that documents information relevant to a client ’ s health care management, e.g. a client chart is a continuing account of client ’ s health care status and need. Conduct training and research work Assess health problems.

12. DEFINITION: Records the memory of the internal and external transactions of an organization. Records contain a written evidence of the activities of an organization in the form of letters, circulars, reports, contracts, invoices, vouchers, minutes of meeting, books of account etc. [ S.L.Geol, 2001 ] 12

13. 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 [ Sr. Mary lucita ] 13

14. PRINCIPLES OF MAINTAINING RECORDS: Specific purpose which should be clearly understood Items on forms and in registers should be conveniently grouped so as to make their completion as easy as possible. The wording should be easily understood, and where doubt is likely to arise, instructions to facilitate interpretation should be included. 14

15. Princip l e s of mai n t aining r e c o r ds (contnd…) Records should permit some freedom of expression. Records which are required by the teaching staff should be easily accessible to them. Person responsible for maintaining records should be aware of their particular responsibility and every effort should be made to keep records up to date and accurate. 15

16. Princip l e s of mai n t aining r e c o r ds (contnd…) Provision for periodic review of all records to ensure that they keep pace with the changing needs of the programme. Adequate supply of stationery to permit records to be maintained on the proper forms and in the proper registers at all times. Su f f i ci e n t numb e r of fil i n g c a b in e ts appropriate equipments to operate a a n d f i l i ng system which is simple and safe and requires the minimum possible time. Adequate, safe, fireproof storage arrangements 16

17. General rules of recording Keep separate records or charts for each individual It’s a legal document, write it in English, clearly accurately Name, age, ward, date and inpatient number should be written on each page All entries should be signed. Chart nursing care and medications and other treatments only after giving them It should be reliable and accurate Information should be factual

18. General rules of recording…. Correct spelling Nurses should not allow others to record Use only standard abbreviations. Do not use ditto marks or chemical formula in charting Each patient should have daily note ,written by nurses on all shifts. The information within a record should be complete Concise data are easily understand

19. General rules of recording…….. Lengthy notes are difficult to read Record immediately after performing nursing activities It should have correctness It should be organized in a logical format order Nurses should maintain confidentiality of patient record Do not use blank space in the record.

20. Accuracy Consciousness Thoroughness Up to date Organization Confidentiality Objectivity 1 /2 4 /2 13 ANU JAMES 20

21. Communication Aids to diagnosis Education Documentation of continuity Research Legal documentation Individual case study 1 /2 4 /2 13 ANU JAMES 21 PURPOSE OF KEEPING RECORDS:

22. USES OF RECORDS Sh o w the h e alth c ond i tions as i t i s and as t he patient and family accepts it. goals towards which means are to be directed. prevents duplication of services and helps follow up services effectively. He l p s t h e nu r se s t o e v alu a t e the c a r e and t h e teaching Organization of work 1 /2 4 /2 13 ANU JAMES 22

23. USES OF RECORDS (contnd….) Serves as a guide for diagnosis treatment and evaluation of services indicate progress Used in research The health assets and needs of the village area 1 /2 4 /2 13 ANU JAMES 23

24. Patients clinical record Individual staff records Ward records Administrative records with educational value. TYPES OF RECORDS 24

25. Patient clinical record operation and anesthesia Out patient and inpatient record Consent form for operation and anesthesia Intake and output chart Graphic charts for TPR Diet chart Doctors order sheet

26. 26 PATIENTS CLINICAL RECORDS It is the knowledge of events in the patient illness, progress in his or her recovery and the type of care given by the hospital personnel. Scientific and legal Evidence to the patient the his /her case is intelligently managed. Avoids duplication of work. Information for medical and legal nursing research. Aids in the promotion of health and care. Legal protection to the hospital doctor and the nurse

27. 1 /2 4 /2 13 ANU JAMES 27 PATIENTS CLINICAL RECORDS (contnd..) NURSING ADMINISTRATOR’S RESPONSIBILITY? Protection from loss Safeguarding its contents Completeness Responsibility for nurses notes. Legal value of nurses notes. Admission record. Scientific value of the nurses notes Record of order carried out.

28. 28 INDIVIDUAL STAFF RECORDS . A separate set of record is needed for staff, giving details of their sickness and absences, their carrier and development activities and a personnel note

29. 29 WARD RECORDS . Reducting or increase in beds. Change in medical staff and non nursing personnel for the ward. The introduction and pattern of support.

30. 1 /2 4 /2 13 ANU JAMES 30 ADMINISTRATIVE RECORDS WITH EDUCATIONAL VALUE. Treatments. Admissions. Equipments losses and replacements. Personnel performance. Other administrative records

31. TYPES OF RECORDS IN THE DEPARTMENT OF PUBLIC HEALTH 31 Cumulative or continuing records Family records Registers Reports

32. FILLING & ARRANGING OF RECORD 1 /2 4 /2 13 ANU JAMES 32 Alphabetically Numerically Geographically With index cards.

33. ALPHABETICALLY Dictionary order Encyclopaedic order 33

34. Advantages and disadvantages of alphabetically arrangement system Most people are familiar Staff should be able to learn and become comfortable with the system in a timely manner The need to shift the records after purging records is reduced Cross reference may be avoided Advantages Disadvantages system does not work well with very large filing systems Color coding is more difficult since you need to have 26 colors or combination of colors to designate all the letters of the alphabet Confidentiality is an issue Some of the rules of alpha filing can be very confusing. 34

35. NUM E RICA L L Y 1 /2 4 /2 13 35 Serial number Digit filing GEOGRAPHICALLY Information is arranged alphabetically by geographical of place name.

36. 36 WITH INDEX CARDS An index card consists of heavy paper cut to a standard size, used for recording and storing small amounts of discrete data. It was invented by Carl Linnaeus, around 1760. Eg:- forms, case records and registers. Diaries- diary of M & F Return – monthly report of HW (M& F) In addition each organization should maintain Cumulative records Family records

37. RECORD KEEEPING SYSTEM 1 /2 4 /2 13 ANU JAMES 37 Source records Problem oriented Nursing cardex Computerized information system

38. 1 /2 4 /2 13 ANU JAMES 38 Computerized information system 3 major categories Clinical system Management information system Educational system

39. GUIDELINES FOR DOCUMENTATION AND RECORD KEEPING 39 The Nursing and Midwifery Council (NMC 2002) has said that patient and client records should: be based on fact, correct and consistent be written as soon as possible after an event has happened be written clearly and in such a way that the text cannot be erased be written in such a way that any alterations or additions are dated, timed and signed, so that the original entry is still clear

40. GUIDELINES FOR DOCUMENTATION AND RECORD KEEPING (contnd..) 40 be accurately dated, timed and signed, with the signature printed alongside the first entry not include abbreviations, jargon meaningless phrases, irrelevant speculation and offensive subjective statements be readable on any photocopies

41. IMPORTENCE OF RECORDS IN HOSPITAL OR HEALTH CENTERS. 41 INDIVIDUAL AND FAMILY FOR THE DOCTOR FOR THE NURSE FOR AUTHORITIES

42. REPORTS 1 /2 4 /2 13 ANU JAMES 42

43. DEFINITION A report containing information against in a narrative graphic or tabular form, prepared on periodic, receiving, regular or as a required basis. Reports may refer to specific periods, events, 1 /2 4 /2 13 ANU JAMES 43 occu r r enc e , or subjec t a n d m a y be oral or c ommun i ca t ed or p r ese n t ed in written form [ Basvanthappa bt.2009 ]

44. DEFINITION (contnd..) 1 /2 4 /2 13 ANU JAMES 44 Reports are oral or written exchanges of information shared between care givers of workers in a number of ways. A report summarises the service of the personnel and of the agency [ Jean b. 2002 ]

45. PURPOSES 1 /2 4 /2 13 ANU JAMES 45 Report is an essential tool to communication To show the kind and amount of services rendered over a specific period. To illustrate progress in teaching goals. As an aid in studying health condition. As an aid in planning. To interpret the services to the public and to the other interested agencies.

46. CRITERIA FOR A GOOD REPORT 1 /2 4 /2 13 ANU JAMES 46 made promptly. clear, concise, and complete. If it is written all pertinent, identifying data are included-the date and time, the people concerned, the situation, the signature of the person making the report. It is clearly stated and well organized Important points are emphasized. In case of oral reports they are clearly expressed and presented in an interesting manner.

47. REPORTS IN NURSING EDUCATION 47 Factual data related to the students, staff, clinical facilities, physical facilities, administration and the curriculum Development made in the school programme since the last report. Proposal and plans for future development. Problems encountered Recommendations

48. TYPES OF REPORTS 24 hours reports Census report Anecdotal report Birth and death report Incidental report 1 /2 4 /2 13 ANU JAMES 48

49. CLASIFICATION OF REPORTS BASED ON TYPES Oral reports Written reports 1 /2 4 /2 13 ANU JAMES 49

50. REPORTS USED IN HOSPITAL SETTING:- 1 /2 4 /2 13 ANU JAMES 50 CHANGE – OF – SHIFT REPORTS TRANSFER REPORTS INCIDENT REPORTS LEGAL REPORTS

51. ADVANTAGES AND DISADVANTAGES OF REPORTS A D V AN T A G E S Monitoring operations Controlling Guide decision Employee motivation Performance evaluation DISADVANTAGES It is time consuming. Expensive Reports can be biased Sometimes implementations of the recommendations of a report become unrealistic. Technical reports are not easily understandable 1 /2 4 /2 13 ANU JAMES 51

52. NURSES RESPONSIBILITY FOR RECORD KEEPING AND REPORTING 1 /2 4 /2 13 ANU JAMES 52 must be functional R e c o r d s and r e p orts accurate, complete, cur r e n t o r g ani z ed and confidential FACTS ACCURACY COMPLETENESS CURRENTNESS ORGANIZATION CONFIDENTIALITY

53. COMMON PROBLEMS THAT OCCUR DURING REPORT WRITING . 1 /2 4 /2 13 ANU JAMES 53 CONTENT AND ORGANIZATION Problem - No section headings Problem - missing items related to the format Problem - lack of numbering

54. Common problems that occur during report writing .(Contnd..) 1 /2 4 /2 13 ANU JAMES 54 GRAMMAR, VOCABULARY, SENTENCE AND TONE . OTHER PROBLEMS Incomplete sentences Confusing and unclear sentences. Miscommunication Too general Confidentiality. Missing information and facts. Wordiness.

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