Nursing Records & Reports
Dr. Kareema Ahmed Hussein
2019-2020
. INTRODUCTION
All professional persons need to be accountable for the
performance اداءof their duties to the public. Since nursing has
been considered as profession, nurses need to record their work
on completion.
Report summarizes the services of the person or personnel and
of the agency.
Records:
A record is a permanent دائمwritten communication that
documents information relevant to a client’s health care
management ذات الصلة بإدارة العميل للرعاية الصحية.
A record is a clinical, scientific, administrative and legal document
relating to the nursing care given to the individual family or
community.
Records are a practical and indispensable aid المساعدات العملية التي ال
غنى عنهاto doctor, nurse and paramedical personnel in giving the
best possible service to their clients.
Recorded facts have value and scientific accuracy صحةfor more than
impression of memory and there are guidelines for better
administration of health services.
Functions of recorded :
1.Supply data that are essential for programmer planning and
evaluation.
2.Provide the practitioner with data required for the application of
professional services for the improvement of family's health.
3. Tools of communication between health workers, the family &
other development personnel
4.Effective health records show the health problem in the family and
other factors that affect health.
5. Indicates plans for future.
6.Help in the research for improvement of nursing care
Recording for Nursing
1. Nurses should develop their own method of expression and
form in record writing. Written clearly, appropriately مناسبand
adequately.كافي
2. Contain facts based on observation, conversation and action.
3. Select relevant facts and the recording should be neat انيق,
complete and uniform موحد
For the Nurse
1.Provide with documentation of services rendered المقدمة, i.e.
shows health
2. condition of the client. Provide data essential for planning and
evaluation of services for further improvement. Serve as a guide for
professional growth.
3. Enable to judge the quality and quantity of work done.
4. Serve as communication tool between staff and other members
5. involved in care. Indicate plans for the future.
5. Valuable legal documents and so it should be handled carefully,
and accounted for.
5. Records should be written immediately after an interview.
6. Records are confidential السريةdocuments.
7. Accurately دقيقةdated, timed and signed Not include
abbreviations, jargon المصطلحات, meaningless phrases.
For the Doctor
1. Serves as guide for diagnosis, treatment, follow up and
evaluation of services.
2. Indicate progress and continuity of care Help self evaluation of
medical practice.
3. Protect the doctor in case of legal issues.
4. Records may be used for teaching and research.
Recording for the individual and family :
1. Records serve to document the history of the client.
2. Records assist in the continuity of care.
3. Records serve as evidence دليلto support or to manage the
legal questions that arise.
4. Records serve to recognize the health needs and can be used
as a research and teaching tool.
For Authorities
1. Provide the management with statistical information
necessary for decision in regard to utilization استغاللof
resources, planning for administrative control and future
references.
2. Help the supervisor evaluate the services rendered المقدمة,
teaching done and a person’s action and reactions.
The patient’s clinical record
1. Records of nurses’ observations
2. Nurses’ Notes
3. Records of treatment
4. Records of admission and discharge
5. Records of equipment loss and replacement ( inventory)
6. Records of personnel performance أداء الموظفين.
Reports
Reports
1. Reports are oral or written exchanges of information shared
between caregivers or workers in a number of ways.
2. A report is the summary of the services of person or
personnel and of the agency.
3. Reports can be compiled daily, weekly, monthly, quarterly and
annually.
4. Report summarizes the services of the nurse and/ or the
agency.
5. Reports may be in the form of an analysis of some aspect
بعض الجوانبof a service.
6. These are based on records and registers and so it is relevant for
the nurses to maintain the records regarding their daily case load
تحميل القضية, service load and activities.
7. Good reports save duplication of effort ازدواجية الجهدand eliminate
that need for investigation to learn the facts in a situation.
8. Full reports often save embarrassment مشاكل ماليةdue to
ignorance جهلof situation.
9. Complete reports give a sense of security which comes from
knowing all factors in the situation.
10. It helps in efficient t فعالةmanagement of the ward.
11. Reports should be made promptly حاالif they are to serve
their purpose well.
12. A good report is clear, complete, concise مختصرا.
13. If it is written all pertinent, identifying data are include the
date and time, the people concerned, the situation, the
signature of the person making the report. It is clearly stated
and well organized for easy understanding.
14. No extraneous خارجيmaterial is included. Good oral reports
are clearly expressed and presented in an interesting manner.
Important points are emphasized وأكد.
Oral reports:
Oral reports are given when the information is for immediate use
and not for permanency ديمومة. E.g. it is made by the nurse who is
assigned to patient care, to another nurse who is planning to relieve
إعفاءher.
Written reports :
Reports are to be written when the information to be used by
several personnel, which is more or less of permanent value, e.g.
day and night reports, interdepartmental reports تقارير مشتركة بين
اإلدارات, needed according to situation, events and conditions.
Types of reports are:
1.Change- of- shift reports or 24 hours report
1.Provide only essential background information about client
(name, age sex, diagnosis and medical history) but do not review
all routine care procedures or task.
2.Identify clients’ nursing diagnosis or health care problems and
other related causes .
3.Describe objective measurements or observations about clients’
condition and response to health problems.
4.Share significant information about family members, as it relates
to clients’ problems. Continuously review ongoing discharge plan.
5.Describe instructions given in teaching plan and clients’
response.
2.Transfer reports
1. A transfer reports involve communication of information about
clients from the nurse on sending unit to the nurse on the
receiving unit.
2. Nurse should include the following information. Client’s name,
age, primary doctor, and medical diagnosis. Summary of
medical progress up to the time of transfer.
3. Current health status- physical and psychosocial. Current
nursing diagnosis or problems and care plan.
4. Any critical assessment or interventions to be completed
shortly. Needs for any special equipments etc.
3. Incident reports تقارير الحوادث
1. The nurse who witnessed the incident or who found the client
at the time of incident should file the report.
2. The nurse describes in concise مختصرwhat happened
specifically objective terms, etc.
3. The nurse does not interpret or attempt to explain the cause
of the incident.
4. The nurse describes any measures taken by the nurse, or
other nurses, or doctors at the time of the incident are
reported.
5. No nurse is blamed in an incident report
6. The report is submitted as soon as possible.
7. The nurse should never make photocopy of the incident
report.
4. Census report تقرير التعداد
1. This is a report compiled daily for the number of patients.
Very often it is done at midnight and the norms are
collected by the night supervisor.
2. The report will show the total number of patients, the
number of admissions, discharges, transfers, births and
deaths.
3. The nurses should remember that a single mistake it is made
buy one of the nurses.
5.Birth and death report
The nurses are responsible for sending the birth and death reports
to governmental authorities for registration within the specified
time.
5.Use terminology in keeping with the nature of
reports:
1. Short, simple, commonly used words for nontechnical
reports.
2. Scientific terms when issuing reports to professional
personnel.
3. Specific rather than general words
4. Use a single meaningful term rather than phrases.
5. Observes mechanics of good writing.
6. Use goods sentences and paragraphs
7. Observe margins هوامش
Thank you
