DR / AMANY LOTFY abd alaziz
professor of med .sur nu
Faculty of nursing – Tanta university
Outlines
1- Introduction
2 Importance of reports and records –
3- Reports.
a) oral reports
b) Written reports
4 –Guideline for written report:
11] Records
kinds of records :-
a) records used in nursing unit
B ) records used in nursing office
Introduction
Reports and records are important
system in every health care
organization. It organized to render
service to the patients by health
providers, and hospital care
administration. The kind and amount
of service rendered in the hospital
depends on the accuracy of
information in reports and records.
purposes of reports and records:
1) provide a way of communication
among the health care providers who
contribute patient care.
2) Used as documentary evidence of
the course of the patient's illness and
treatment during hospitalization.
3) Serve as a basis for analysis, study
and evaluation of the quality of care
rendered to patient.
4) Provide clinical data for research
and education.
5) Provide continuity of patient care
6) Serve as a basis of planning
individual patient care.
7) Assist in protecting the legal
interests of the client, health
organization, and health care
providers.
Reports.
Report is a document form which
include ; conclusions or findings
based on facts, or recommendations
concerning them.
Reports should be clear, concise
and accurate.
The supervisor and head nurse
responsibility to instruct personnel
how using all forms
Kinds of reports :•
It can be :
a) oral reports
b) Written reports.
A)oral reports:
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 to the physician ,
supervisor, etc
B) Written Reports:
It includes:
1-Day, evening and night
report.
2-Incident report.
3-Report of complain . .
4-Report including negligence. .
5-Reports for requisition. .
1- Day, Evening and night
report:
Are written summaries of patient's
information about their condition and
activities that related to their care as: -patient
census.
- All acutely ill and post - operative patient.
- Patients with and change in general
condition, e.g. vital signs or those who had
special treatment.
- Admissions discharges, transfers and
deaths during the shift.
- Patients scheduled for operations or
special investigations.
2. Incident report:
Any happening which is not consistent
with routine of hospital operation or
patient care. It may be an incident or a
situation, which might result in an
accident , E.g. error on medication and
omission of the treatment ,...
it is an important administrative tool for
use in studying cause of accident in the
hospital by providing information which
lead to effective preventive measures and
in case of legal actions.
Should include:
- Patient's name and diagnosis.
- Time of incident noted or reported.
- What was done.
- Date and signature of individuals
involved in the incident
3-Report of complain:
Serious complaints , which cannot de
handled by the ward personnel , are
reported to the nursing office. The report
should include :
- Statement of complaint E.g. pain .
- Justification as seen by the nurse.
- Measures taken to overcome the
dissatisfaction.
- The result of action taken.
- Date and signature.
4. Report for negligence:
is a report including carelessness or disregard
of regulations on the part of a member of the
nursing personnel to the nursing office.
5. Reports for requisitions:
Written requests for supplies equipment or
service to be sent from the unit to the
concerned department
Guideline for written report:
1. Have the patient's name and hospital
number on every sheet.
2. initiate each entry with the date and
time.
3. Chart after providing care, not before.
4. Chart as soon and as possible .
5. Chart only your own observation, care ,
and teaching.
6. Be objective in charting.
.
Guideline for written report
7. use only hard - pointed , permanent
black ink pens .
8. be timely , specific , accurate , and
complete.
9. use concise phrase , begin each phrase
with capital letter and each new topic on
a separate line.
10.use only approved abbreviations and
medical terms .
Guideline for written
report
11 .use medical terminology only if you
are sure of its meaning.
12.follow rules of grammar and
punctuation.
13.fill all spaces. Draw a horizontal line
in unused space.
14.correct errors in documentation as
soon as possible.
15.do not erase the error or use
correction fluid.
16.Draw a single line through any
erroneous information, write the
words "error " or "error in charting"
above it along with your name , and
write the entry correctly.
17.put entries in order of
consecutive shifts and days.
18. sign each block of charting or
energy with full legal name and title
11] Records: السجالت
Are administrative tools used to
classify and prevent duplication
of the information.
An Administrative-
Educational
Research objectives.
Kinds of Records:
a) records used in b) records used in
nursing unit nursing office
1-patient record 1. Master record of
2-assignment . nursing hours .
record.
3- time record 2. attendance record.
4- census record. 3. personnel record .
5.-inventories a. Employment
record. record,
6.-narcotics and b. Evaluation
medication record
record
A) Records used in nursing unit:
1. Patient record:
It is an orderly written form of
patient condition, which include
findings, treatment and patient's
progress that provide sufficient
information about the period of
hospitalization and the care
given.
Patient record
includes: data of admission.
A- Admission and discharge records.
B- Medical and physical examination.
C- Medical progress notes .
D- Physician orders
E- Graphic records as temperature ,
intake and output, etc ...
F- Vital signs record .
G- Medication administration record .
H- Discharge plan .
Nurse's notes AS an example of
pt.record should include:
- Date, time and manner of admission
(wheel chair crutches ...)
- Statement of apparent condition of the
patient.
- Record of symptoms noted.
- Treatment.
- Time and type of specimen.
- Signature should include full name and
professional status
Importance of nurses
notes:
- Provide an accessible form
followed by nurses.
- Transfers responsibility from the
nurse to other.
- Makes it possible to review readily
and quickly the patient's
- Other records as anesthesia records,
radiology, and x-ray test, etc...
2. Assignment records:
Are records containing the assigned
duties for each nursing staff member.
The record should include:
- Name of the head nurse.
- Name and position of nursing
personnel assigned during the shift.
- Name of the patient, diagnosis,
investigations to be done.
- List of special assignments.
Importance of this record:
- To inform nursing staff in writing about
the patient for whose nursing care and for
special assignment.
- To maintain for fixing responsibilities
for nursing care .
- To evaluate the nursing care given and
for discussing and conducting conference
(on duty conference) .
3. Time schedule record:
It is a weekly or monthly record, which
indicates the planned coverage of nursing
personnel for each nursing unit. The form
should include
- name of all categories of nursing
personnel on the unit
- days off and vacations and
the various categories of personnel being
groups for a week or for 24 hours.
Purpose of time schedule
record:
- shows the coverage for the
unit
- Records the presence and
absence of nursing personnel.
- Give information about service
rendered
4. Patient census record:
it is a daily record for each unit from
which the official patient census of the
hospital is derived.
The unit clerk under supervision of
the head nurse. The form includes;
number of beds in the unit and sent to
the proper administrative offices.
Inventory record:
4. It is a form used for recording
all articles of furniture.
Equipment and instruments with
the received date, and quantity of
each element of articles.
Importance of the inventory
record:
- Provide head nurses with
information upon which to request
needed either replacements
because of loss or breakage.
- Identify and replace the missing
items, and all borrowed articles are
returned.
b) Records used in nursing
office:
1. Master record of nursing
hours:
This record derived from the time
schedule records of the nursing
units and should show the
distribution of the hours for each
nursing personnel in the hospital.
2. Attendance record:
3. Personnel record:
It is concerned with information
about each individual nurse ,
assembled in a file , which includes :
- copied application.
- Photograph.
- Basic nursing education and
professional preparation
- Evaluation records.
This records should be the
responsibility of the assistant
director for personnel in the
nursing office.
The personnel record consists of:
a. Employment record includes:
- Position on employment.
-Professional preparation.
-Registration number.
-Date of employment.
-Date of promotion.
-Date and reasons for termination of
employment.
-Summary of nurse's achievement,
weaknesses and recommendations.
b. Evaluation record:
It is filled periodically for all nursing
personnel and indicates professional
progress of the nurse. Importance of
evaluation records:
- an objective basis on which to base
personnel promotion.
- An incentive to individual progress.
- Provides reason for poor performance
The areas for evaluation that need to be
included in the record are:
1. Nursing abilities, efficiency and quality of
performance.
2. Attitudes and relationships with patients,
workers and supervisors.
3. Attitudes towards and achievement of self
development.
4-Represent the opinion of more than one
supervisor.
- Match the following from column A to column B (5 marks):
Answer
Term Definition
1- Inventory record a-record containing the
assigned duties for each
nursing staff member.
2- Patient census record b-its weekly or monthly
record
3- Assignment record c-is an orderly written form
of patient condition
4- Time schedule record d- It is a form used for
recording all articles of
furniture.
5- Patient record e- Daily record which the
official census of the
hospital is derived.
1 2 3 4 5
E-Learning course
activities
List types of records &
reports used in nursing
unites & nursing office ?
