١
Documentation
(Records and Reports)
By
D/ Rasha Mohammed Nagib Ali Lecture of Nursing Administration
Minia University- Faculty of Nursing
Outlines
-Definitions of records and reports
-Importance of records and reports
-Kinds of reports
Oral Reports-
Written reports-
Guideline for written report-
Kinds of Records-
Records used in nursing unit-
Records used in nursing office:-
٢
Documentation It is the process of communicating in written form about essential facts for the maintenance of continuous history of events over a period of time.
Records is the permanent written communication that documents information relevant to a client’s health care management.
Reports : Summarizes the services of the person or personal and of the agency . Or are oral or written exchange of information shared between nurses or a number of persons.
٣
Importance of records and reports Documentation””
1- Communication
2- Planning Client Care
3- Auditing Health agencies
4- Research
5-Education
6- Reimbursement
7- Legal Documentation
8- Health Care Analysis
٤
٥
(a) Oral Report
Are given when information is needed to be reported immediately not for permanency, e.g. oral reports given by head nurse to all personnel, reports about patient condition and needs.
Telephone Reports
Inform physician of changes
Client transfers to different units
Result reports from lab or radiology
Client transfers to different institutions
Keep clear, accurate, repeat info if necessary
٦
(b) Written reports
1- Day, evening and night report 2- Incident report.
3- Report of complain.
4- Report including negligence.
5- Transfer report
6- Reports for requisition.
7-Birth and death report 8-Anecdotal report
٧
٨
٩
١٠
: Report of complaint
Serious complaints, which cannot be handled by the ward personnel, are reported to the nurse office. The report should include:
Statement of complaint.
Justification as seen by the nurse.
-Measures taken to overcome the dissatisfaction.
The result.
Date and signature.
١١
: Report indicating negligence
Is a report including carelessness or disregard of regulations on the part of a member of the nursing personnel to the nursing office.
Reports for requisitions:
Written requests for supplies, equipment or service to be sent from the unit to the director of nursing office
١٢
Guideline for written report:
1. Have the patient’s name and hospital number.
2. Initiate each entry with the data and time.
3. Chart after providing care, not before.
4. Chart as soon as possible.
5. Chart only your own observation, care, and teaching.
١٣
7- Use permanent black ink pens.
8- Use concise phrase, begin each phrase with capital letter and each new topic on a separate line.
9- Use only approved abbreviations.
11- Use medical terminology.
12- Fill all spaces.
13- Draw a single line through any erroneous information.
14- Sign each block of charting.
١٤
Writtien
١٥
١٦
Kinds of Records
(b) Records used in nursing office (A) Records used in
nursing unit
1- Master record 1- Patient record
2- Attendance record 2- Assignment record
3- Personnel record 3- Time record
Employment record 4- Census record
Evaluation record 5- Inventories record
: A. Nursing unit records
1- Patient record:
It is an orderly written report of patient complaints.
The diagnostic findings are treatment and patient's progress that in total contains sufficient information about the period of hospitalization and the care given. This record should be arranged in
chronological order from the current data back to the data of admission.
١٧
It includes:
1. Admission and discharge records 2. History of physical examination 3. Progress notes:
4. Physician's orders 6. Vital signs record:
5. Graphic record 6. Vital signs record:
7. Nurses' notes
Date Time Nurse note
Unit
Shift Date
١٨
Importance of nurse's notes:
- Provides an accessible form, which may be readily consulted and followed by nurses.
- Transfers responsibility from the nurse to others, as orders may be readily reviewed.
- Makes it possible to review readily and
quickly the patient's condition and all records
for patient care.
١٩
: . Assignment records 2
Assignments are records of the names of nursing personnel and the patients assigned to their care. There is a special form to be filled daily by the head nurse or the team leader for each shift and should be located in place accessible to all nursing personnel.
record . Time
3
It is a weekly record, which indicates the planned
coverage of the nursing personnel for each
nursing unit. It should be made in duplicate,
one copy is retained in the unit and the other is
sent to the nursing office
٢٠
. Census record 4
It is a daily record for each unit from which the official census of the hospital is derived. It could be filled by the unit clerk and under the supervision of the head nurse. The form
includes:Number of beds in each unit.
The census of the patients.
: . Inventories record 5
It is an itemized record for all articles of furniture, equipment and instruments with identity date of quantity and all elements of the articles. Inventory count ' should be made at periodic times as hospital policy indicates. There are certain items that need to be counted frequently, such as instruments and syringes. Furniture and linen count is made throughout the hospital at least once a year.
٢١
Importance of the inventory:
- Furnishes head nurses with information upon which to request replacements needed either because of loss or breakage.
- All articles in excess of the standard number are returned to the proper department.
- Location of missing items and all borrowed
articles are returned
٢٢
‘Keeping good nursing records allows us to identify problems that have arisen and the action taken to rectify them’
٢٣
