UNIT II Maintenance of patients Records and Reports

Introduction Record is a clinical, scientific administrative and legal document relating to the nursing

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

Importance and purposes Decision-making Planning client care Communication Education Research: Records are the secondary

Contd. . • • • 3/4/2021 Auditing Quality assurance monitoring Vital statistics It serves

Importance of records in hospital or health centers For the individual and family: •

For the doctor • It serves as a guide for diagnosis, treatment, follow up

For the nurse • It shows health condition of the client • It provides

For authorities • Records help the supervisor to evaluate the service rendered • It

CHARECTERISTICS • • • Factual Accurate Complete Current Organized 3/4/2021 copyright www. brainybetty. com

Principles of record writing • • 3/4/2021 As records serves as legal document All

• • 3/4/2021 It should be written continuously with no blank spaces. Each

Types of records • RECORDS USED IN THE COMMUNITY SET UP • NURSING RECORDS

NURSING RECORDS USED IN HOSPITAL SET UP • Clinical records • General wards records

Clinical records • It is used in the hospital; investigations special procedures and treatments

Types of clinical records • • • Nurse treatment register Graphic chart of T.

General wards records • • • Admission discharge and transfer records. Census records Inventory

Nursing office records • • • Master record of nursing hours Personal records Employment

RECORDS IN NURSING EDUCATION AND ADMINISTRATION-as per INC recommendations • A) RECORD CONCERNING STUDENTS

B) RECORDS CONCERNING STAFF Application form Copy letter of appointment Job description Record of

• C) GENERAL COLLEGE RECORDS • The written philosophy, purposes and curriculum of

• • Written policies of the college Statement of budget proposals Course curriculum

• Various committee records • Inventory records • Maintenance records. 3/4/2021 copyright www.

MEDICAL RECORDS • Medical records can be defined as an orderly written document encompassing

purposes • To provide means of communication among, physician, nurses, and other allied health

Format of medical records. • • • 3/4/2021 Source oriented medical records Integrated medical

• Source oriented: -Conventional methods -The record is divided in section as physician’s

• Integrated medical records: • These arranged in a strict chronological order, regardless

• • Common record keeping forms. Admission nursing history forms Flow sheets and

CARE OF RECORDS • The records are kept under the safe custody of the

• All records are to be handled carefully • All records are filed

REPORTS • Reports are oral or written exchange of information, shared between nurses in

DEFINITION • Reports offer a summary of activities or observations seen, performed or heard

PURPOSES AND IMPORTANCE • • 3/4/2021 To show kind amount of service rendered over

Contd • • • 3/4/2021 To interpret the service to the public and to

contd • • • 3/4/2021 Accurate reports helps in efficient management of the departments.

CRIETERIA FOR A GOOD REPORT – Reports should be made promptly and confidentiality has

PRINCIPLES OF REPORTING • Report should be truthful, accurate, appropriate, clear, confidential, brief, complete

Contd • It will help the personnel to plan the future care of patients

TYPES OF REPORTS • 3/4/2021 Oral report: Oral reports are given where the information

a) Reports among the members of the health team b) Reports between the head

CONTD • 3/4/2021 Written reports: It should be concentrate on the past, present and

CONTD a) Reports on mistakes, accidents, and complaints b) Evaluation reports c) Day evening

contd • Analytical reports : eg purchase of new plant or machinery, proposals for

MIS reports • These are the management information system report, which is best suited

The reports used in hospital setting. • • Change of shift report Transfer report.

Nursing office report: • Monthly report: • It is a statistical report of such

• Annual report: • It includes annual statistics for the items covered in

LEGAL IMPLICATIONS IN RECORD AND REPORT MAINTENANCE • Informed consent is essential before surgery

• Checking of labels appearance of drug and also should be charted accurately

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UNIT II: Maintenance of patients Records and Reports Mrs. Indumathi Lecturer YNC

Introduction Record is a clinical, scientific administrative and legal document relating to the nursing care given to individual, family, or community. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 2

Definition A record is a permanent written communication that documents information relevant to the management. (Basavanthappa, 2000). 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 3

Importance and purposes Decision-making Planning client care Communication Education Research: Records are the secondary source for data collection.

Contd. . • • • 3/4/2021 Auditing Quality assurance monitoring Vital statistics It serves as a guide to professional growth. Good records are time savers They reveal the problems in the organization. copyright www. brainybetty. com 2006 All Rights Reserved 5

Importance of records in hospital or health centers For the individual and family: • Records serve to document the history of the client • Records assist in the continuity of care • It serve to recognize the health needs and can be used as a research and teaching tool 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 6

For the doctor • It serves as a guide for diagnosis, treatment, follow up and evaluation of services • Records indicate progress and continuity of care • It helps self-evaluation of medical practice. It protects the doctor in case of legal issues 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 7

For the nurse • It shows health condition of the client • It provides data essential for planning and evaluation of services • It serves as a guide for professional growth. • It enables to judge the quality and quanty of work done. • Serves as a communication tool between staff and other members involved in care. • Records indicate plans for future. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 8

For authorities • Records help the supervisor to evaluate the service rendered • It help in the guidance of staff and student • It helps the administrator to assess the health assets and needs of the community. • It serves as a legal evidence of the service rendered 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 9

Principles of record writing • • 3/4/2021 As records serves as legal document All entries should be signed by the individual who writes them. Care to be taken not to make any errors on the records. It should be written in chronological order as to date and time. copyright www. brainybetty. com 2006 All Rights Reserved 11

• • 3/4/2021 It should be written continuously with no blank spaces. Each page of the record should be properly identified with name, age, bed number, ward, date etc. Use only standard abbreviations. Records should be truthful, brief and complete. copyright www. brainybetty. com 2006 All Rights Reserved 12

Types of records • RECORDS USED IN THE COMMUNITY SET UP • NURSING RECORDS USED IN HOSPITAL SET UP • RECORDS IN NURSING EDUCATION AND ADMINISTRATION 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 13

Clinical records • It is used in the hospital; investigations special procedures and treatments are written and signed. Importance 1. It helps in the diagnosis and treatment of the patient. 2. Serves as a means of communication 3. Act as a legal document 4. As a proof of work done 5. To complete the medical record. 6. Serves as a record of the patient’s condition and care rendered. 7. Serves as a time saver for healthy team members. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 15

Types of clinical records • • • Nurse treatment register Graphic chart of T. P. R Out patient and inpatient records Intake and output chart Nurse’s observation chart 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 16

General wards records • • • Admission discharge and transfer records. Census records Inventory record: Narcotic records: Assignment record 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 17

RECORDS IN NURSING EDUCATION AND ADMINISTRATION-as per INC recommendations • A) RECORD CONCERNING STUDENTS Application forms and other reports: Record of student clinical experience A progress report Final record Health record 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 19

B) RECORDS CONCERNING STAFF Application form Copy letter of appointment Job description Record of the staff member’s educational qualification, any short term course attended participation in seminars, conference, professional activities such as contribution of articles & journals. • Periodic evaluation or progress record • Leave record • Health record • • • 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 20

• C) GENERAL COLLEGE RECORDS • The written philosophy, purposes and curriculum of the school • Accreditation records a) Permission from govt to start college b) Affiliation from INC/ state council 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 21

• • Written policies of the college Statement of budget proposals Course curriculum records Prospectus Record of research publications and project Minutes of staff meeting Records of the stock 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 22

MEDICAL RECORDS • Medical records can be defined as an orderly written document encompassing the patient’s identification date, health history, physical examination findings, laboratory reports treatment and surgical procedures. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 24

purposes • To provide means of communication among, physician, nurses, and other allied health care professionals. • To serve as an easy reference for providing continuity of care. • To serve as an informational document to assist in the quality review of patient care. • To render clinical and administrative data required for budgeting, management, service development, planning, medical education and medical research. • To generate statistics vital for societal review, planning and allocation of health care resources 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 25

• Source oriented: -Conventional methods -The record is divided in section as physician’s note, Laboratory reports, nurses notes and so forth. -In each section, entries are arranged in a chronological order. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 27

• Integrated medical records: • These arranged in a strict chronological order, regardless of the source of original data. • -Here a physician’s order may be followed by a consultation report or by a nurses note. • Problem oriented medical records. (POMR) • which enumerate the patient’s problem as a single entity, listing the diagnostic and therapeutic steps for each problem. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 28

• • Common record keeping forms. Admission nursing history forms Flow sheets and graphic records Client education record Client care summary or kardex Acuity charting Discharge summary forms. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 29

CARE OF RECORDS • The records are kept under the safe custody of the nurse in each ward (not accessible to the patients and visitors) • No individual sheet is separated from the complete record • Records are not handed over to the legal advisors without the written permission of the administrator. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 30

• All records are to be handled carefully • All records are filed according to the hospital custom • All records are identified with the biodata of the patient such as name, age, ward, bed no, IP no, diagnosis etc • Records are not sent out of the hospital without the doctor’s permission. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 31

REPORTS • Reports are oral or written exchange of information, shared between nurses in a number of ways. • The purpose of reporting is to communicate specific information to a person to person or group of people. A report should be concise and contains pertinent information. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 32

DEFINITION • Reports offer a summary of activities or observations seen, performed or heard which is exchanged among health care team members, clients, and family members. • Reporting is a communication of information to another or a group of individuals which may be written or oral. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 33

PURPOSES AND IMPORTANCE • • 3/4/2021 To show kind amount of service rendered over a specific period To illustrate progress in reaching goals. As an aid in studying health conditions. As an aid in planning. copyright www. brainybetty. com 2006 All Rights Reserved 34

Contd • • • 3/4/2021 To interpret the service to the public and to the other interests agencies. Complete reports establish the nurse’s accountability. It shares significant information about family members as it relates to client’s problems. copyright www. brainybetty. com 2006 All Rights Reserved 35

contd • • • 3/4/2021 Accurate reports helps in efficient management of the departments. Good reports create confidence in the employees. Good reports save duplication of effort and eliminate the need for investigation to learn the facts in a situation. copyright www. brainybetty. com 2006 All Rights Reserved 36

CRIETERIA FOR A GOOD REPORT – Reports should be made promptly and confidentiality has to be maintained. – It should be clear, concise and complete. – Should be well organized for easy understanding. – Should be presented in an interesting manner. – Should emphasize the important points. – A good report is un hurried. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 37

PRINCIPLES OF REPORTING • Report should be truthful, accurate, appropriate, clear, confidential, brief, complete and legible. • Good reports will indicate the efficiency of the health team in carrying out their assignments. • Good reports will avoid duplication of work. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 38

Contd • It will help the personnel to plan the future care of patients without wasting time unnecessary. • Good reports tell us about the problems relating to supplies and equipments. • Use only standard abbreviations. • All entries should be signed by the individual who writes them. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 39

TYPES OF REPORTS • 3/4/2021 Oral report: Oral reports are given where the information is for immediate use and not for permanency. It is made by the nurse who is assigned to patient care to another nurse who is supposed to relieve her. copyright www. brainybetty. com 2006 All Rights Reserved 40

a) Reports among the members of the health team b) Reports between the head nurse and her assistant c) Reports between the head nurse and the nursing superintendent d) Reports to the physician 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 41

CONTD • 3/4/2021 Written reports: It should be concentrate on the past, present and future state of the patient or event. Reports are written when the information is to be used by several people or is more or less of permanent value. copyright www. brainybetty. com 2006 All Rights Reserved 42

CONTD a) Reports on mistakes, accidents, and complaints b) Evaluation reports c) Day evening and night report d) Census report e) Interdepartmental reports. f) Interagency reports. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 43

contd • Analytical reports : eg purchase of new plant or machinery, proposals for solutions to management problems. • Information reports : eg simple accident reports, some financial report etc • MIS reports 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 44

MIS reports • These are the management information system report, which is best suited for the middle level managers as they are more concerned with planning and controlling. MIS provides summarized reports on the organizations performance, which can give them a basis for making organizational plans. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 45

Nursing office report: • Monthly report: • It is a statistical report of such information relating to the nursing department as may be needed for administrative and accounting purposes, such as numbers of various types of personnel, new employees, resignation, average nursing hours provided per patient in clinical divisions, distribution of nursing personnel and days of absence. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 47

• Annual report: • It includes annual statistics for the items covered in the monthly reports, recommendations • for the improvement of nursing service. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 48

LEGAL IMPLICATIONS IN RECORD AND REPORT MAINTENANCE • Informed consent is essential before surgery or investigation for the patients. • Confidential records and reports should be shown to authorized person only. • Registration of birth, death and still births are the important vital events. • Medicines should be administered as per the order of the doctor and also under supervision. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 49

• Checking of labels appearance of drug and also should be charted accurately before administration • Recording and reporting accidents, errors and incompetent behaviors. • Identification of babies in labour ward by disks. • Identification of dead bodies in mortuary. 3/4/2021 copyright www. brainybetty. com 2006 All Rights Reserved 50