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.