Embed Size (px)
DESCRIPTION
Records and Reports. By. D/ Ahlam EL- Shaer Lecture of Nursing Administration Mansoura University- Faculty of Nursing. Outlines. - Definitions of records and reports - Importance of records and reports - Kinds of Records - Records used in nursing unit - PowerPoint PPT Presentation
Citation preview
Records and Records and ReportsReports
BByy D/ Ahlam EL-ShaerD/ Ahlam EL-Shaer
Lecture of Nursing Lecture of Nursing AdministrationAdministration
Mansoura University- Faculty Mansoura University- Faculty of Nursingof Nursing
Outlines -Definitions of records and reports -Importance of records and reports - Kinds of Records - Records used in nursing unit - Records used in nursing office: - Kinds of reports - Oral Reports - Written reports - Guideline for written report
Records Are administrative tools used
to classify and prevent duplication of the information.
Reports Report is a document form
which include; conclusions or findings based on facts, or
recommendations concerning the patient.
Importance of records and Importance of records and reportsreports
Provide a way of communication among the health care providers
Used as documentary evidence of the course of the patient illness and treatment during hospitalization.
Serve as a basis for analysis, study and evaluation of the quality of care rendered to patient.
Provide clinical data for research and education.
Provide continuity of patient care on subsequent admissions of the patients.
Serve as a basis for planning individual patient care.
Assist in protecting the legal interests of the client, health organization, and health care providers.
Kinds of Records
((AA ) )Records used Records used in in nursing unitnursing unit
((bb ) )Records used Records used in in nursing officenursing office
11 - -Patient recordPatient record11 - -Master recordMaster record22 - -Assignment recordAssignment record22 - -Attendance Attendance
recordrecord33 - -Time recordTime record33 - -Personnel Personnel
recordrecord44 - -Census recordCensus record Employment Employment
recordrecord55 - -Inventories recordInventories record Evaluation Evaluation
recordrecord66 - -Narcotics and Narcotics and
Medication recordMedication record
Kinds of reportsKinds of reports
It can be -:
Oral report )a(
(b )Written report.
(a) (a) Oral Report 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.
((bb ) )Written reportsWritten reports
It includes:
1 -Day, evening and night report.
2 -Incident report.
3 -Report of complain.
4 -Report including negligence.
5 -Reports for requisition.
Guideline for written Guideline for written reportreport::
1.1. Have the patientHave the patient’’s name and hospital s name and hospital number.number.
2.2. Initiate each entry with the data and Initiate each entry with the data and time.time.
3.3. Chart after providing care, not Chart after providing care, not before.before.
4.4. Chart as soon as possible.Chart as soon as possible.
5.5. Chart only your own observation, Chart only your own observation, care, and teaching.care, and teaching.
6- Be objective in charting.
7- Use permanent black ink pens.
8- Be 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.
11 -Use medical terminology.
12 -Follow rules of grammar.
13 -Fill all spaces.
14 -Correct errors in documentation.
15 -Don’t erase the error.
16 -Draw a single line through any erroneous
information .
17 -Sign each block of charting.
