PRESENTATIONON

USE OF COMPUTERS IN HOSPITAL AND COMMUNITY, PATIENT RECORD SYSTEM,

NURSING RECORDS AND REPORTS

SUBJECT:-NURSING MANAGEMENT

SUBMITTED TO:- SUBMITTED BY:-

Mr.V.K David Ms. Eudora Blah

M.Sc (N) Child Health Nursing M.Sc (N) 2nd yr

Lecturer Student

College of Nursing College of Nursing

Dhamtari Dhamtari

1. INTRODUCTION

The invention of computers started the revolution of Information Technology (IT) in the

world, bringing modern concepts into the world. In the past few decades, offices, factories and

business adopted computers to enhance their performance. The next were the households to adopt

the computers as their new form of entertainment. Today, computers, along with Internet

technology are being introduced into hospitals to enhance the performance of the medical facilities

that are dispensed. In the following paragraphs some important uses of computers in hospitals have

been described. Apart from that the advantages of using computers to advance health care have

also been discussed.

Hospitals today are bringing computers closer to the health care professionals and closer to

the patients in order to increase efficiency, but also increase accuracy. Computers are often wall-

mounted or deployed at all nurses’ stations within a hospital in order to ensure that patients’ charts

are more easily accessible and updated more accurately. Computers may also be mounted on

medical carts with secure medication dispensing systems that ensure that patients receive the right

medications at the right time, every time – reducing the chance of error and increasing patient

safety. These same computers mounted on carts can be used to interact with the patients at their

bedside, displaying lab and radiological results, and engaging patients in private real-time

discussions with their doctors regarding their diagnosis and treatment.

Other areas within the hospital are increasing their computer use as well. Laboratory

facilities and radiological departments use PCs to conduct tests, but also enter results into patients’

medical records. Doctors may collaborate with other specialists and colleagues outside the hospital

using telemedicine – a computer-based communication and data sharing system. Administrative

departments, medical billing departments and the reception desk or information center all use PCs

to keep the hospital running. Going forward, every department within a hospital facility will be

using computers, with software that ties everything into one system within the hospital and external

to the hospital: collaborators, insurance providers, laboratories, testing facilities, and patients

themselves.

2. COMPUTER USES IN HOSPITAL AND COMMUNITY

USES IN COMMUNITY

When it comes to importance of computers in Hospitals, it is undoubtedly an important

aspect to keep in the pace of the technologically advanced world. Healthcare is again a field where

technology has made things lot better and increased the efficiency in patient care. Below are some

of the points which highlight the uses of computers in hospitals.

Storage of Patient Data: For any organization proper and systematic storage of information is a

mandate requirement. Nurses can use computers to take down and store notes of the patients, as

they observe their condition while on rounds. As the supervised rounds involve a lot of patients and

a lot of information, using a computerized personal digital assistant makes it easier to access the

right medical information at the right time instead of carrying a bunch of paper work and then take

time to search the piece of paper to access information when you need to be quick, efficient and

accurate.

Computerized Presentations: We all would agree that computerized power point presentations are

much more efficient and has more impact on the receiver when it comes to presenting data. Even in

the field of nursing education, computers help the nursing tutors/educators to present the large and

complicated detailed form of data, which of course is a part of the medical study, in a very

simplified and effective form. When speaking of uses of computers in medicine, features like power

point presentations, slide shows, and videos are used to present medical procedures and techniques

for better understanding of complex medical procedures and their treatments.

Teaching nurses through Simulations: The field of medicine involves the concept of "hands-on

work". I mean be it a doctor or a nurse, countless procedures are done on patients regularly. Nursing

education therefore, must involve a lot of practice programs to make the students efficient to face

the real life scenario. Computer programs which enable simulate such procedures therefore are of

great use.

Computerized Self Evaluation: Computers also contribute and help the students know their

strengths and weaknesses. There are many computerized quiz and medical tests with immediate

feedback that can help you brush and develop your medical facts and requirements without any

delay. Your queries are solved, you know the answers and you know where you stand. A regular

use of such computer applications definitely makes you more equipped and well researched for your

field.

Interactive Learning: Among the uses of computers in education, the most appealing and

outstanding feature of computer based education is that it gives boost to interactive learning.

BASICS ABOUT A COMPUTER SYSTEM:

A computer system is an electronic device similar to TV, DVD, etc. It accepts the requests

through commands and processes the requests to output the results.

In any hospital we have a procedure of file system to keep the records of the patients visiting the

hospital. These records will be stored in a department called Medical Records section for the

future follow-ups.

USING COMPUTERS TO ADVANCE HEALTH CARE

Using computers in health care can improve the quality and effectiveness of care and reduce its

cost. However, adoption of computerized clinical information systems in health care lags behind use

of computers in most other sectors of the economy.

Improved Quality Automated hospital information systems can help improve quality of care

because of their far-reaching capabilities.

Hospital information systems (HMS) in a hospital can combine the use of computers for storing and

transferring information with using them for giving advice to solve clinical problems.

In addition to alerting physicians to abnormal and changing clinical values, computers can generate

reminders for physicians.

For complex problems, computer workstations can integrate patient records, research plans, and

knowledge databases.

Computers and databases can be used to compare expected results with actual results and to help

physicians make decisions.

The lives of patients can be improved if they use computer systems to obtain information, make

difficult decisions, and contact experts and support groups.

Decreased Costs When a physician orders a test by computer, it can automatically display

information that promotes cost-effective testing and treatment.

USES OF COMPUTERS IN HOSPITALS

Computers are being included in hospitals and medical clinics throughout the world. Some uses of

computers in hospitals and clinics have been described in the following paragraphs.

Application of Computers in Hospitals

Importance of computers in medicine is growing and spreading rapidly. The only disadvantage is

that a full fledged installation of all the computerized systems in hospitals is a lengthy and costly

process. There are however, some hospital systems which already work on the basis of computers.

Here's an explanation to all such systems, which work on computers…

Uses of Computers in Hospitals:

a. Medical Data

Every day hospitals and clinics which are attached to it churn out enormous volumes of data

regarding patients, ailments, prescriptions, medications, medical billing details, etc. Such medical

records, are now a day‘s recorded into medical billing software. Such mammoth databases are

known as Electronic Medical Records (EMR) and Electronic Health Records (EHR). These

databases are operated by a set of computers and servers, and come in handy during medical alerts

and emergencies. The concept of EHR is a bit broader than the EMR, as the database is accessible

from different clinics and hospitals. Thus, a patient's medical history can be retrieved from any

hospital by medical practitioners.

b. Medical Imaging

'Tests' are medical procedures where specified components of the human body are scanned. A test

can be as simple as a regular blood test or it can be a complex CT /MRI scan. This process is often

referred to as a medical imagery. In order to increase the precision of such procedures, computers

have been adopted and integrated into the testing equipment. The Ultrasound and the MRI are the

best examples where computers have been adopted, in order to make the process faster and precise.

Thus medical tests and tools have become more advanced as a result of the use of computers.

c. Medical Examination

Many systems are underway for the development of medical monitoring which will help humans to

properly monitor their own health. In many cases doctors and surgeons also use sophisticated

computer aided equipment to treat their patients. Such systems and procedures include, bone scan

procedure, prenatal ultrasound imaging, blood glucose monitors, advanced endoscopy which is used

during surgery and blood pressure monitors. Basically these medical tests and tools provide

significant convenience to medical practitioners. You will find that major laboratory equipment and

heart rate monitors have already been computerized in many hospitals.

Advantages of Computers in Hospitals

There are significant advantages of using computers in hospitals. The importance of computers in

hospitals has also increased drastically due to the fact that the procedures have to be speedy to

cater to a larger population and the medical services have to be more precise.

To sum up, the advantages of computers in hospitals can be summarized as follows:

Precise 'tests' and medical examinations

Faster medical alerts, which are more accurate time-wise

Enhanced data about a patient‘s medical history

Precision in diagnosis

Precision in billing

Automated updating of medical history

The possibility of computers uses in the medical field are endless, facilitating medical help to

hospitals and clinics all across the globe. I hope that the elaboration of the uses of computers in

hospitals is resourceful.

3. PATIENT RECORD SYSTEM

ELECTRONIC PATIENT RECORD SYSTEM

The EMR can be defined as the legal patient record created in hospitals and ambulatory

environments that is the data source for the EHR.

It is important to note that an EHR is generated and maintained within an institution, such as

a hospital, integrated delivery network, clinic, or physician office, to give patients,

physicians and other health care providers, employers, and payers or insurers access to a

patient's medical records across facilities.

The 2003 Patient Safety Report describes an EMR as encompassing:

1. A longitudinal collection of electronic health information for and about persons

2. Immediate electronic access to person- and population-level information by authorized

users;

3. Provision of knowledge and decision-support systems [that enhance the quality, safety, and

efficiency of patient care] and

4. Support for efficient processes for health care delivery.

Need of an hour

a. If there's one constant in the healthcare industry, its change. Healthcare providers are driven to

find new ways to cut costs while improving care.

b. To meet these challenges, healthcare is turning to information systems to control costs,

improve overall efficiency and enhance patient care.

Need of an hour

a. A case in point in the medical records arena is the completion of patient charts. While greatly

improved through imaging, this remains a costly, laborious process which has a tremendous

impact on healthcare enterprises.

b. Systems must evolve to find a way to automate the identification of deficiencies in patient

charts. They must also enable electronic routing of incomplete documents to appropriate

medical and administrative personnel for on-line processing, completion and reporting and

include advanced features like electronic signature.

c. Integrated health care delivery system-need of efficient and accurate ways of capturing,

managing and analyzing clinical data. Payers and regulators asking the report card on clinical

process and outcome

Need for CPR

To manage escalating health care cost

Evolving role of primary health care

Guidelines are being promoted to reduce the variances of clinical practices

Integrated delivery system

Key Capabilities of an Electronic Health Record System

To capture data at the point of care

To integrate data from multiple internal and external sources

To support caregiver decision making. core capabilities

Health information and data: Having immediate access to key information - such as patients'

diagnoses, allergies, lab test results, and medications - would improve caregivers' ability to make

sound clinical decisions in a timely manner.

Result management: The ability for all providers participating in the care of a patient in multiple

settings to quickly access new and past test results would increase patient safety and the

effectiveness of care.

Order management: The ability to enter and store orders for prescriptions, tests, and other services

in a computer-based system should enhance legibility, reduce duplication, and improve the speed

with which orders are executed.

Decision support: Using reminders prompts, and alerts, computerized decision-support systems

would help improve compliance with best clinical practices, ensure regular screenings and other

preventive practices, identify possible drug interactions, and facilitate diagnoses and treatments.

Electronic communication and connectivity: Efficient, secure, and readily accessible

communication among providers and patients would improve the continuity of care, increase the

timeliness of diagnoses and treatments, and reduce the frequency of adverse events.

Patient support: Tools that give patients access to their health records, provide interactive patient

education, and help them carry out home-monitoring and self-testing can improve control of chronic

conditions, such as diabetes.

Administrative processes: Computerized administrative tools, such as scheduling systems, would

greatly improve hospitals' and clinics' efficiency and provide more timely service to patients.

Reporting: Electronic data storage that employs uniform data standards will enable health care

organizations to respond more quickly to federal, state, and private reporting requirements,

including those that support patient safety and disease surveillance."

Hall mark of CPR

1. Integrated view of patient record:

2. Improving the access of all patient data, whenever and wherever is necessary

3. Tang et al ,(1998) observational studies of physician they noted 81% physician did not find all

data of the patient for treatment

4. Access to knowledge sources:

5. Personal knowledge reference s data may be useful

6. Physician order entry and clinician data entry:

7. Physician order initiate the clinical intervention

8. When its entered by the clinician responsible for care the accuracy and quality of the data are

high

9. Integrated communication support:

10. Clinicians need integrated communication support for effective functioning of

multidisciplinary outpatient health care system

11. Relying on paper based references become ineffective and fallible

12. Clinical decision support

ADVANTAGES

Improve quality of care

1. The implementation of electronic health records (EHR) can help lessen patient sufferance due

to medical errors and the inability of analysts to assess quality.

2. EHR systems are claimed to help reduce medical errors by providing healthcare workers with

decision support.

3. Computerized Physician Order Entry (CPOE)—one component of EHR—increases patient

safety by listing instructions for physicians to follow when they prescribe drugs to patients.

Naturally,

4. Promote evidence-based medicine

5. EHRs provide access to unprecedented amounts of clinical data for research that can

accelerate the level of knowledge of effective medical practices.

6. Realistically, these benefits may only be realized if the EHR systems are interoperable and

wide spread (for example, national or regional level) so that various systems can easily share

information.

Record keeping and mobility

1. EHR systems have the advantages of being able to connect too many electronic medical

record systems.

2. In the current global medical environment, patients are shopping for their procedures.

Coordinating these appointments via paper records is a time-consuming procedure.

3. It is also easier to check in their records whether a patient as been admitted to such a medical

centre or if they have any allergies since they have been admitted before.

4. Replace paper-based medical records which can be incomplete, fragmented (different parts in

different locations), hard to read and (sometimes) hard to find. Provide a single, shareable, up

to date, accurate, rapidly retrievable source of information, potentially available anywhere at

any time. Require less space and administrative resources.

5. Potential for automating, structuring and streamlining clinical workflow.

6. Provide integrated support for a wide range of discrete care activities including decision

support, monitoring, electronic prescribing, electronic referrals radiology, laboratory ordering

and results display.

7. Maintain a data and information trail that can be readily analyzed for medical audit, research

and quality assurance, epidemiological monitoring, disease surveillance.

8. Support for continuing medical education.

9. The meaningful use of EHRs intended by the US government incentives is categorized as

follows:

10. Improve care coordination

11. Reduce healthcare disparities

12. Engage patients and their families

13. Improve population and public health

14. Ensure adequate privacy and security

15. Disadvantages

16. They spend more time entering data into an empty EHR than they used to spend updating a

paper chart with a simple dictation.

17. Such hurdles can be overcome once the software has some data, as physicians learn to use

templates for data entry, and as workflow in the practice changes, but not every practice gets

that far.

18. Surveyors found that hospital administrators and physicians who had adopted EHR noted that

any gains in efficiency were offset by reduced productivity as the technology was

implemented, as well as the need to increase information technology staff to maintain the

system.

19. Often, doctors do not want to spend the time to learn a new system. Some doctors believe that

adopting a system with EHRs could reduce clinical productivity

20. Governance, privacy and legal issues

21. In Western countries, the concept of a national centralized server model of healthcare data has

been poorly received. Issues of privacy and security in such a model have been of concern.

22. Records that are exchanged over the Internet are subject to the same security concerns as any

other type of data transaction over the Internet.

ISSUES

1. Integrated systems require consistent use of standards in e.g. medical terminologies and high

quality data to support information sharing across wide networks

2. Ethical, legal and technical issues linked to accuracy, security confidentiality and access

rights are set to increase as national EMR systems come online.

3. Common record architectures, structures

4. Clinical information standards and communications protocols

5. Security and confidentiality of information

6. Patient data quality; data sets, data dictionaries

Storage of records

The required length of storage of an individual electronic health record will depend on

national and state regulations, which are subject to change over time. While it is currently unknown

precisely how long EHRs will be preserved, it is certain that length of time will exceed the average

shelf-life of paper records. Ruotsalainen and Manning have found that the typical preservation time

of patient data varies between 20 and 100 years.

Synchronization of records

When care is provided at two different facilities, it may be difficult to update records at both

locations in a co-ordinated fashion. Two models have been used to satisfy this problem: a

centralized data server solution and a peer-to-peer file synchronization program Synchronization

programs for distributed storage models, however, are only useful once record standardization has

occurred. Merging of already existing public healthcare databases is a common software challenge.

The ability of electronic health record systems to provide this function is a key benefit and can

improve healthcare delivery.

4. NURSING RECORD AND REPORT

RECORDS

All professional persons need to be accountable for the performances of their duties to the

public. Since nursing has been considered as profession, nurses need to record their work on

completion.

DEFINITION

“A record is a permanent written communication that documents information relevant to a

client’s health care management.”

“A record is a clinical, scientific, administrative and legal document relating to the nursing

care given to individual family or community”.

The records are a practical and indispensable aid to the doctor, nurse and premedical

personnel in giving the best possible service to their clients. Recorded facts have a value and

scientific accuracy for more than mere impression of memory and there are guidelines for better

administration of health services. Records are the means of communications between health

workers and their clients.

Health records refer to forms on which information about clients i.e. socio-economic, psychological

and environmental factors are maintained.

PURPOSES

Records serve the following purposes.

- Records provide data for programme planning and evaluation

- Records are the tools of communication between the health workers, the family and other

development personnel.

- Records indicate plans for the future

- Records provide baseline data to estimate the long term changes related to the services.

- Records provide an opportunity for evaluating the services.

- Records help in the research for improvement of nursing care.

- Records help in the research for improvement of nursing care.

Every organization keeps some kind of records. In community settings the health care agency

maintains certain records under following headings:-

1. Forms, Case cards and Registers.

- Family and village record

- Eligible couple and child register.

- Sterilization and IUD register.

- MCH Card/Register

- Child Card/Register

- Birth and Death register

- Sub-centers/PHC/Clinic registers.

- Stock and Issue register.

- Reports of Blood stain of Malaria and Filaria.

- Malaria Parasite Positive case register and others.

2. Diaries -Diary of (M and F)

-Diary of HA (M and F)

3. Return -Monthly report of HW (M and F)

-Compilation report of HA (M and F)

-PHC Monthly report

In addition, each organization should maintain:-

i. Cumulative records

ii. Family records.

Likewise every department in the hospital has its own records, such as:-

i. The patient’s clinical record

ii. Records of nurses’ observation-Nurses’ Notes

iii. Records of orders carried out

iv. Records of treatment

v. Records of admission and discharge

vi. Records of equipment loss and replacement (Inventory)

vii. Records of personnel performance.

IMPORTANCE OF RECORDS IN HOSPITAL OR HEALTH CENTERS

A medical record should finish all health care providers with concise, accurate, written picture

of patients medical and nursing problems, care planned and given, and the patients response to

treatments.

The chart or health care record has been more important in the health care system than it is

today. It is a legal record than in used to meet the many demands of the health, accreditation,

medical insurance, and legal system.

A nurse must understand how to use these records effectively and efficiently.

The service of nursing personnel will be meaningful only when it is properly recorded and

maintained. Records have following advantages to the individual and family, the doctor, the

nurse, the authorities, and also contribute to the education and research and health planning.

For the Individual and Family

The records help individual and family to become aware of and to recognize their health needs

under the following headings:-

- Records serve to document the history of the client.

- Records assist in the continuity of care

- Records serve as an evidence to support or to refute the legal questions that arise.

- Records serve to recognize the health needs and can be used as a research and teaching tool.

For the Doctor

- Records serves as guide for diagnosis, treatment, follow-up and evaluation of services.

- Records indicate progress and continuity of care.

- Records help self-evaluation of medical practice.

- Records protect the doctor in case of legal issues.

- Records may be used for teaching and research.

For the Nurse

- The record provides with documentation of services rendered i.e. shows health condition of

the client.

- Records provide data essential for planning and evaluation of services for further

improvement.

- Records serve as a guide for professional growth.

- Records enable to judge the quality and quantity of work done.

- Records serve as communication tool between staff and other members involved in care.

- Records indicate plans for the future.

For the Authorities

- Records provide the management with statistical information necessary for decision in

regards to utilization of resources, planning for administrative control and future references.

- Records furnish documentary evidences for proposals of evaluation of care in terms of

quality, quantity and adequacy.

- The records help the supervisor to evaluate the services rendered, teaching done and a

person’s actions and reactions.

- The records help in the guidance of staff and students when planned, records are utilized as

an evaluation tool during conferences.

- Records help the administrator assess the health assets and needs of the community.

- Records serve as a legal evidence of the services rendered by each employee or worker. It

protects the organization in the event of legal questions.

- Records provide justification of expenditure of funds.

REPORTS

DEFINITION

“Reports are oral or written exchanged of information shared between caregivers or workers in a

number of ways.”

A report summarizes the services of the personnel and of the agency. Reports are usually written

daily, weekly, monthly or yearly.

PURPOSES

Ideally the reports are written for the following purposes:-

- To show the kind and amount of services rendered over a specific period.

- To illustrate progress in reaching goals.

- As an aid in studying health conditions.

- As an aid in planning.

- To interpret the services to the public and to the other interested agencies.

Probably no other single factor is more vital for good administration than prompt and complete

reports. They save duplication of efforts and eliminate the need for investigators to learn the facts in

situation.

CLASSIFICATION

Reports may be classified as oral and written.

1. Oral reports: Oral reports are given when the information is for immediate use and not for

permanency. For example, oral report is made by the nurse who is assigned to patient care,

to another nurse who is planning to relieve her, and some of the oral reports may be made to

charge nurses and nurse supervisors and also doctors.

2. Reports are to be written when the information is to be used by several personnel, which is

more or less of permanent value, for example day and night reports, census,

interdepartmental reports and other special reports, needed according to situation, events and

conditions.

REPORTS IN HOSPITAL

The reports used in hospital setting usually are change-of-shift reports, transfer reports, incident

reports, day, evening and night reports, legal reports.

1. Change-of-shift reports:- These may be given orally in person by audiotaping, recording,

pr during rounds at the clients’ bedside some of the points to be kept in mind while giving

such reports are as follows:-

- Provide only essential background information about client (name, sex, age, diagnosis and

medical history) but do not review all routine care procedures or tasks.

- Identify clients’ nursing diagnosis or health care problems and other related causes but do

not review all biographical information on case sheets.

- Describe objective measurements or observations about clients’ condition and response to

health problem. Stress recent changes, but do not use critical comment about clients’

behavior.

- Share significant information about family members as it relates to clients’ problems. Do not

make any assumptions about relationship between family members.

- Continuously review ongoing discharge plan. Don’t engage in idle gossip.

- Relay to staff significant changes in the way therapies are given. Do not describe basic steps

of a procedure.

- Describe instruction given in teaching plan and clients’ response. Do not explain detailed

content unless staff members ask for clarification.

- Evaluate results of nursing or medical care measures. Do not simply describe results as good

as poor. Be specific.

- Be clear on priorities to which oncoming staff must attend. Do not force oncoming staff to

guess what to do first.

2. Transfer-report:- Patients will frequently be transferred from one unit to another to receive

different levels of care. A transfer report involves communications of information about

clients from the nurse on sending unit to the nurse on the receiving unit. When giving

- Client’s name, age, primary doctor, and medical diagnosis.

- Summary of medical progress up to the time of transfer.

- Current health status-physical and psycho-social.

- Current nursing diagnosis or problems to be completed shortly.

- Needs for any special equipment etc.

3. Incident reports:- Nurses usually becomes involved in client-related incidents as some point

in their careers. They must understand the purpose of incident reporting, the following

points are to be kept in mind:

- The nurse who witnessed the incident or who found the client at the time of incident should

file the report.

- The nurse describes in concise what happened specifically objective terms etc.

- The nurse does not interpret or attempt to explain the cause of the incident.

- The nurse describes objectively the clients, conditions when the incident was discovered.

- Any measures taken by the nurse, other nurses, or doctors at the time of the incident are

reported.

- No nurse is blamed in an incident report.

- The report is submitted as soon as possible to the appropriate authority.

- The nurse should never make photocopy of the incident report.

4. Legal reports:- Incident reports and reports on accidents, mistakes and complaints are legal

nature. There are times when a hospital is criticized for what is claimed to be negligence or

poor care because of a condition that resulted in discomfort and perhaps serious harm to a

patient or client. In such reports, the content is stated briefly and objectively giving all

pertinent information. Accuracy, timeless, completeness and relevancy to the problems are

maintained promptly while making such reports.

NURSES RESPONSIBILITY FOR RECORD KEEPING AND REPORTING

Nurses have legal responsibility for accurately reporting and recording patients conditions,

treatments and responses to care.

The medical record is a written or computerized account of a patient’s illness and treatment that

includes information submitted by all members of the patient health care team.

The medical record is an information source document that should be used to plan care, evaluate

care, allocate costs, educate personnel, research care measure and substantiate legal claims.

Court decisions have stated that the patient’s medical record is essential to proper care and the

medical record is the property of the health agency.

However, the patient has a property right information contained in the report, the patient has a

right to inspect and copy the record after being discharged.

However, it is unadvisable to allow a patient to review his or her medical record without

medical supervision and explanation because a patient is likely to misunderstand certain records

notations.

Failure to record significant patient information on the medical record makes a nurse guilty of

negligence when the patient is injured because of a doctor’s ignorance of significant information

about medical history, signs and symptoms.

The medical record must be accurate to provide a sound basis for care planning. Therefore,

errors in nurse charting must be corrected promptly in a manner that leaves no doubt about the

facts.

Every health agency should have a policy and protocol that directs that an erroneous chart entry

be crossed through labeled as erroneous signed by the employee who corrects the error, and

retained in the patient’s record.

Correct information should then be documented to replace the erroneous and corrected entries

should never be destroyed.

Nurses who conspire with doctors and others to falsify patient’s record for purposes of

concealing a criminal violation may be found criminally liable.

Generally, the person who makes reports required by statute is immune from suit under the

doctrine of the public’s right to know. In many countries there are statutes that require health

personnel to report instances of child abuse, ophthalmic neonatrum, communicable diseases,

birth out of wedlock gunshot wounds, suicide, rape and use of unprescribed narcotics. In

reporting information about criminal acts obtained during patient care, the nurse

communication. Several aspects of statutory, case and administrative law control nursing

practice and nursing management.

GOOD REPORT

Records and reports must be functional, accurate, complete, current organized and confidential.

1. Fact

Information about clients and their care must be functional. A record should contain descriptive,

objective information about what a nurse sees, hears, feels and smells. In the same way, anything

happens during the managing the affairs in the institutions/hospital, manager should document

inferences or constitution with functional information to avoid misleading, misinterpretation and

any error in administration.

2. Accuracy

A client record must be reliable. In other words, information must be accurate so that health team

members have confidence in it. The use of correct measurements ensures that a record is accurate.

3. Completeness

The information within a recorded entry or a report should be complete, containing concise and

thorough information about a client care or any event happening taking place in the jurisdiction of

manager.

4. Currentness

Delays in recording or reporting can result in serious omissions and untimely delays for medical

care or action legally, a late entry in a chart may be interpreted on negligence.

5. Organization

The nurse or nurse manager communicates information in a logical format or order. Health team

members understands information better when it is given in the order in which it occurred.

Confidentiality

Nurses are legally and ethically obligated to keen information about clients illnesses and treatments

confidential. In the same way certain information in management also should be kept confidential.

CONCLUSION

Any information about clients care or event taking place in the health care agencies should be

communication with careful thought. All members of health team depend on recorded and reported

information. Accurate information ensures continuity and quality of care and also smooth running

of administration.

BIBLIOGRAPHY

1. Brown Montouge. Nursing Management issues and ideas. 1992

1st edition. An Aspen Publication

Pp-92-94

2. Gullatte .Mary Magee Nursing management principles and practice.2005

Pp-390-391

3. Marquis Bessie L, Hutson Carol Jorgensen. Leader roles and management functions in

nursing. 2009. 6th edition, Wolters Kluwer

Pp-509-510

4. Nagelkerk Jean. Leadership and Nursing care management.2005.

3rd edition Saunders publication

Pp-201-202.

5. Tomey Ann Marriner. Guide to nursing management and leadership.2009

8th edition, Mosby Elsevier

Pp- 219-220.