Records and Reports PDF

Records and Reports 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 Int...

Records and Reports 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 Introduction Records and reports are important system in every health care organization. It is organized to render service to the patients by health care providers, and hospital administration. The kind and amount of service rendered in the hospital depends on the accuracy of information in records and reports. 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 reports 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. RECORDS Their usefulness must be judged by the contribution they make to an administrative , educational and research objectives.  Kinds of Records (A) Records used in (b) Records used in nursing unit nursing office 1- Patient record 1- Master record 2- Assignment record 2- Attendance record 3- Time record 3- Personnel record 4- Census record Employment record 5- Inventories record Evaluation record 6- Narcotics and Medication record 1.patient record It is on orderly written form of patient condition, which includes diagnostic findings, treatment and patient's progress that provide sufficient information about the period of hospitalization and the care given. This record should be arranged in chronological order from the current data back to the data of admission. The form should include: a-Admission and discharge records. b-Medical and physical examination. c-Medical progress notes. d-Physician's orders. e-Graphic records as pulse, temperature, intake and output, etc… f-Vital signs record. g-Medication administration record. h-Discharge plan. i-Nurses' notes: j-other records as anesthesia records, radiology, and x-ray test, etc.. Nurse’s notes begin with the admission of the patient to the unit and should include: -Date, time and manner of admission (wheel chair, crutches, …). -Statement of apparent condition of the patient. -Record of symptoms noted. -Treatment instituted. -Time and type of specimen, signed by the nurse who rendered the service. Signature should include full name and professional status. Importance of nurse’s notes: Provides an accessible form, which may be readily consulted and followed by nurses. Transfers responsibility from the nurse to others, as orders may be readily reviewed. Makes it possible to review readily and quickly the patient’s condition and all records for patient care. 2-Assignment records: Are records containing the assigned duties for each nursing staff member. There is a special form to be developed by the head nurse or the nurse in-charge for each shift and should be located in place accessible to all nursing personnel. The record should include: -Name of the head nurse. -Name and position of nursing personnel assigned during the shift. -Name of the patient, diagnosis, investigations to be done. -Time and place of conference or meeting -list of special assignments. Importance of this record To inform the nursing staff in writing about the patient for whose nursing care they are responsible and for any special assignment. To maintain for fixing responsibilities for nursing care. To evaluate the nursing care given and for discussing and conducting conference “ on duty conference 3-Time schedule record It is a weekly or monthly record, which indicates the planned coverage of the nursing personnel for each nursing unit. It should be made in duplicate, one copy is retained in the unit and the other is sent to the nursing office. The form should include name and vacations and the various categories of personnel being groups for a week or for 24 hours. Purpose: Shows the coverage for the unit and therefore helps to determine whether the coverage is adequate or not. Records the presence and absence of nursing personnel. Give information about services rendered. The hours could be calculated in the office to check against the standards. 4-Patient census record: -It is a daily record for each unit from which the official patient census of the hospital is derived.It could be filled by the unit clerk under supervision of the head nurse. The form includes; number of occupied beds, unoccupied beds and total beds in the unit. Patient census record sent to the proper administrative offices.The form should be taken at fixed time of the day or night as hospital policy. 5-Inventory record: -It is a form used for recording all articles of furniture, equipment and instruments with the received date, and quantity of each element of articles. Inventory count should be made periodically as hospital policy indicates. There are certain items that need to be counted frequently, such as instruments and syringes. Furniture and linen count is made throughout the hospital at least once a year. Importance of the inventory record : Provides the head nurses with information upon which to request replacements needed either because of loss or breakage. All articles in excess of the standard number are returned to the proper department. Identify and replace the missing items , and all borrowed articles are returned. (B): Records used in nursing office: 1-Master record nursing hours; -this record derived from the time schedule records of the nursing units and should show the distribution of the hours for each category of nursing personnel in the hospital. 2-Attendance record: 3-personnel record: -It is concerned with information about each individual nurse, assembled in a file ,which includes: -Copied application. - Photograph. -Basic nursing education and professional preparation. -Evaluation records. -These records should be the responsibility of the assistant director for personnel in the nursing office. The personnel record for non-professional persons should be kept in the personnel department. The personnel record consists of: a. Employment record: -It includes -position on employment. -professional preparation. -registration number. -date of employment. -date of promotion. -date and reasons for termination of employment. -summary of nurses achievement, weaknesses and recommendations. This record should be revised periodically either annually or semi-annually for additional professional preparations. b. Evaluation record: It is filled periodically for all nursing personnel and indicates professional progress of the nurse. : Importance of evaluation records -an objective basis on which to base personnel promotion. an incentive to individual progress.- -provides reason for poor performance ,as well as recommendations for work well done. ORGANIZATION OF THE MEDICAL RECORD The basic methods of organizing the medical record include the traditional source-oriented narrative record and the more innovative problem-oriented medical record. 1. Source-oriented narrative record: The record requires members of each department (the source) to record information in a separate section in the medical record (e.g. laboratory results, diagnostic radiology report and doctors' progress notes) Advantages of this method: Make it easy for each department to give the patient's related to findings in a quick time. Disadvantages: Segregating entries according to the department discourages communication among health care providers The medical record reader must consult various parts of the record to gain a complete picture of the patient's care. 2. Problem-oriented medical record: This type of record emphasizes on the patient and his problems by defining each problem and its suitable solution(s) so that the logical sequence of thoughts and decision-making can be readily described. The record consists of : Base line data: The information gathered relates to the patient's social and emotional status, medical status, health history, initial assessment findings, and diagnostic test results.  Problem list: The current patient's nursing problems are identified from the base line data. Each problem must be dated and numbered. The problem maybe active, resolved or potential one. Plan of care: Which addresses each of the patients' problems, which are routinely updated both in the plan of care and in the progress notes. Progress notes: Spell out in a factual plan from the actual progress of the patients' condition using Subjective, Objective notations and Assessment and Plan that result from those notations (SOAP ).  Kinds of reports It can be :- (a) Oral report (b) Written report.  (a) 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.  (b) Written reports It includes : 1- Day, evening and night report. 2- Incident report. 3- Report of complain. 4- Report including negligence. 5- Reports for requisition. 1-day, evening and night report: Are written summaries of patient's information about their condition and activities that related to their care. Day, evening and night report as: -patient census. -All acutely ill and post-operative patient. -patients with any change in general condition, e.g. vital signs or those who had special treatment. -admissions, discharges, transfers and deaths during the shift. -patients scheduled for operations or special investigations. Two copies are made, one remains in unit and other is sent to the nursing services office to provide them with information about the patients' conditions and related activities for their care. 2-Incident report: Any happening which is not consistent with routine of hospital operation or patient care. It may be an incident or a situation, which might result in an accident, e.g. error in medication and omission of the treatment, etc.. It is an important administrative tool for use in studying cause of accident or incident in the hospital by providing information which lead to effective preventive measures and in case of legal actions.  The form should include: -patient's name and diagnosis. -time of incident. -details of the incident. -what was done. -date and signature of all individuals involved in the incident and their professional status. 3-Report of complain: Serious complaints, which cannot de handled by the unit personnel, are reported to the nursing office. The report should include: -statement of complaint. -justification as seen by the nurse. -measures taken to overcome the dissatisfaction. -the result of action taken. -date and signature. 4-report including negligence. Is a report including carelessness or disregard of regulations on the part of a member of the nursing personnel to the nursing office. 5-Reports for requisitions: Written requests for supplies, equipment or service to be sent from the unit to the concerned department.  Guideline for written report: 1. Have the patient’s name and hospital number. 2. Initiate each entry with the date and time. 3. Chart after providing care, not before. 4. Chart as soon as possible. 5. Chart only your own observation, 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- Write neatly and legibly. 12- Use only approved abbreviations and medical terms. 13- Use medical terminology only if you are sure of its meaning. 14- Follow rules of grammar and punctuation. 15- Fill all spaces. Draw a horizontal line in unused space. 16- Correct errors in documentation as soon as possible. 17- Do not erase the error or use correction fluid.