COMMUNICATION LEADERSHIP PART II

PART I - Importance of Communication in

Nursing Leadership

1. Communication processes vary among

groups regarding the patterns and
channels used and the degree to which
the communication flow is open or
closed.
2. Communicating is basic to the process
of influencing and thus to leadership. It
is based on mutual understanding.
3. The leader's vision and message is
received by the followers after choosing
a channel the sender transmits a
message , but the message is filtered
through the receivers perception.
4. Communication is transmitted through
both verbal and nonverbal modes.
5. Communication is a process by which a
meaning is assigned to the needs,
feelings, perceptions, and
interpretation of what is brought to our
awareness.
6. Successful health care outcomes are
dependent on clear communication;
therefore all nurses need proficiency in
interpersonal skills.
7. Nurse leaders and managers need to
be mentors, coaches, and role models
for effective interpersonal and team
communication in order to ensure safe
patient outcomes, effective teamwork,
and staff satisfaction.
8. Organizations include a variety of
communication structures and flows.
This may be downward , upward ,
horizontal , grapevines , or the network's
communication may be formal or
informal.

THE NURSING SERVICE
“ NURSING SERVICES as the part of the total
health organization which aims to satisfy the
major objective of the Nursing Services and that
is- prevention of disease and promotion of
health”
Nursing Service constitutes
- BACKBONE of the health care system
- Nursing group-40% to 50% of the total
workforce
- Largest health care workforce in the
clinical setting
- Collaborates, coordinates and integrates
- Constantly present at the bedside
monitoring patients
- Pivotal in significantly influencing
patient clinical outcomes and
satisfaction for the entire population it
served.
VISION
The nursing Service envisions to be globally
recognized in providing excellent health care and
allied services to all Filipinos and other Clients
MISSION
- Provide quality and culturally competent
nursing personnel through research,
learning and development in adherence
to international standards and
accreditation.
- Guarantee equitable, sustainable, and
quality healthcare
- Establish performance standard
- Participate in the development on
improving local communities, self-
reliance and participatory decision-
making
PHILOSOPY
The Nursing Service believes and respects that
patients have the right to receive holistic and
quality care regardless of race, age, creed,
gender, culture, religion, political affiliation and
socio-economic status.
Committed to asses and meet the physiological,
physical, psychological, emotional, spiritual,
social, rehabilitative, and financial needs of
every patient served in the community.
Life-long learning, research, innovative
strategies, professional nursing practice and
education.
CORE VALUES IMPORTANCE OF PLANNING

- Integrity Principal duty of every nurse manager in all

- Commitment management levels for the following reasons:
- Compassion
❑ Alignment of nursing unit/department and
STRATEGIC GOAL financial and strategic plan.
- Service-oriented ❑ Establishes framework for decision making
- Dynamic consistent with top management objectives
- Empowered health care force
❑ Forces analytic thinking and evaluations of
CONCEPTUAL FRAMEWORK alternatives, thereby improving decision-making
Shows the functions and respective roles of the
❑ Ensures safe quality care through awareness
Nursing Service Administrators.
of individual responsibility and accountability
A clear understanding of this process and how
IMPORTANCE OF PLANNING
they are applied in different organization levels
are necessary to achieve the objectives and goals - Communication and team collaboration
set by the agency. - Basic for managing organizational and
individual performances
NURSING SERVICE DEPARTMENT IN THE
- Cost-effectiveness> utilization of
PHILIPPINES
resources, facilities, utilities and
As an administrator the Chief Nurse basically services.
performs the major management functions - Improve organizational systems and
namely: Planning, Organizing, Staffing, Directing, processes
Controlling - Discovers the need for change that leads
to create new services and productivity.
- Manages risk and copes with crisis
PLANNING situations

First Management function that primarily deals CHARACTERISTIC OF A GOOD PLAN

with the future. It entails forecasting of setting - Plan is written
the broad outline of the work to be done. - Define the nursing business
- What, Why, Where, How, Who - Contains both general and specific
- First Management process defined by objectives
FAYOL - Defines strategies
- Continuous process, beginning with - Support the mission
setting goals and objectives - Details forecasted activities for a year or
- Laying out plan of action for longer than one year
accomplishing them - Developed with inputs from clinical
- Putting them into play nurses and line managers
- Reviewing the process and outcomes - Addresses resources such as personnel
- Providing Feedback to personnel and facilities
- Modifying the plan as needed - Changes are evident
(ROUSSEL, 2006) - Financial plan is included
 - Needs are identified and supported FIVE STEP PROCESS IN SUCCESION PLANNIING
- Priorities are included
1. Identify key areas and positions
- Timetables are listed
2. Identify capabilities for key areas and
- It is based on current data analysis
position
- It assesses both strength and
3. Identify interested employees and
weaknesses
assess them against capabilities
- Derives from a good nursing
4. Develop and implement succession and
management information plan
knowledge transfer plan
- It used and modifies consistency
5. Evaluate effectiveness
TYPES OF PLANNING
TOOLS IN PLANNING
STRATEGIC
SWOT ANALYSIS
Continuous systematic process that emphasize
assessment organizational environment ❑ STRENGTH (extraordinary reputation,
(external and internal) services, clinical experts, supportive leadership,
high performing team)
Economic, political, social, and technological
factors ❑ WEAKNESSES ( need improvement; poor
patient care, understaffing, vague organizational
Focuses on performance improvement and direction – goals)
utilizes strategies to accomplish the
organization’s desired outcomes ❑ OPPORTUNITIES ( absence of dominant
competitors, advancement in technology,
OPERATIONAL training specialty hospital)
Detailed work plan or written blueprint in which
❑ THREATS (low retention rate, lack of highly
the objectives of nursing unit/department are
skilled nurses, low salary, statutory laws
put into measurable actions.
affecting the nursing practice.
Clear picture how a team, nursing unit,
department will contribute to the achievement
of the organization’s strategic goals. ORGANIZING

Also known as Management Plan CHARACTERISTICS OF AN ORGANIZATIONAL

Patient satisfaction, safety, internal process,
staffing, training and education research, and
financial.
NURSING SUCCESSION PLANNING
- Strategy for identifying and developing
potential future nursing leaders who can
replace them in case of retirement,
reparation from service or any inevitable
circumstances to ensure continuity of
leadership and services.
STRUCTURE
1. Division of work – each box represents an
individual or sub-unit responsible for a given task
of the organizations work load
2. Chain of command – reflected in the
organization structure with a solid line, or known
as line of authority. Who reports to whom (can
be flat (shared an equal power) or tall)
3. Type of work to be performed – indicate the
level or description in boxes.
4. The groupings of work segment or
homogenous assignments – shown by cluster of
works
TYPES OF ORGANIZATIONAL STRUCTURE
1. Formal Structure – shows relationship among
employees and their job positions. Describe the
tasks, responsibilities and relationship. Can be in
a DIAGRAM called the ORGANIZATIONAL CHART.
2. Informal Structure – Based on social
relationship rather than on positional authority.
(People who are meeting in a particular place or
time with social needs or personal needs)
Organizational chart and its implication
- A line drawing composed of boxes that show
how the parts of an organization are linked.
- Depicts formal organizational relationship,
areas of responsibility, persons to whom one is
accountable for and channels of communication.
Two lines in organizational chart
o Unbroken Solid Lines
▪ Solid horizontal line represent communication
between people with similar spheres of
responsibility and power but different functions.
▪ Solid Vertical line between position denote the
official chain of command and formal path of
communication and authority.
NOTE: Those having the greater decision –
making authority are at the top; those with the
least are at the bottom.
o Broken Solid line
▪ Used dotted or broken lines which represent
staff position, the people that provides
information or assistance to the manager but has
limited organizational authority (function is in
advisory capacity)
Characteristics of Organizational Effectiveness
- There is a strong transformational leadership
- There is high employee morale
- There are shaped goals, which are already
cascaded (clear/well-informed department).
- Learning and development of staff are
maximized.
o Team Building – the process of
gathering the right people and getting them to
work together for the benefit of a project and
evaluation of the team.
ORGANIZING THE NURING SERVICE
Process of identifying and grouping the work to
be performed, defining and delegating
responsibility and authority and establishing
relationships for the purpose of enabling people
to work most effectively together in
accomplishing the objectives (Lows Al Allen,
2011). It follows planning as a second phase of
the management process
PURPOSE OF ORGANIZING
1. Formulate a team so that they may work
together to achieve objectives
2. Assign activities with an authority that
can supervise the team
3. Design a formal system so that roles are
clear, everyone knows who is to do,
what and who is responsible for what
results
4. Establish a positive work environment
for the staff to effectively accomplish
their goals
5. Collaborate and coordinate productively
within and outside their department,
STEPS IN ORGANIZING - Function task to produce the product
- General manager responsible to the
Consider the plans and goals of the organization
report of the product manager
Determine the work activities necessary to
accomplish objectives

Classify and group activities that are interrelated

Assign work and delegate appropriate authority

Design and hierarchy of relationships both

horizontal and vertical 4. HYBRID STRUCTURE
- The structure of a large organization that
has many divisions and simultaneously
FORMS OF ORGANIZATIONAL STRUCTURE uses many different types of
organizational structure.
1. HIERARCHIAL
- (tall. Centralized, bureaucratic)
- Commonly called LINE STRUCTURE
(RANKING)
- Line of communication (downward)

STAFFING

- Functions consist of identifying work

force requirements, recruiting,
interviewing, selecting, hiring,
2. DECENTRALISED promoting, appraising, and orienting
- (flat, horizontal, participatory) staffs that tasks are accomplished
- If you are the brain behind that project effectively and efficiently.
then you will be part of the management - Crucial, complex, and time-consuming
function. Program head decision-making function of a nurse manager.
- Involves filling and keeping filled, the
positions in the organization structure.
- Scheduling, staff development,
employee socialization, and team
building are also often included as
staffing position.

3. MATRIX
- Focus both product and function
Importance of staffing - Influences nursing personnel to follow the
direction
- Recruits competent personnel
- Becomes means of motivation
-Allocate job tasks properly among nursing - Helps in efficient utilization of resources
personnel according to their qualifications and - Initiates action
specialization - Provides stability

- Provides the numbers and mix of nursing staff CONTROLLING

needed per nursing unit
- Ensures adequate and equitable manpower for
efficient and effective delivery of nursing care.
-Optimize the utilization of nursing human
resource at the least manpower cost but high on
quality nursing care.
- Measuring performance against goals and
plans, showing where deviations from standard
exist and helping to correct deviations from
standards.
- Controlling function includes performance
appraisals, fiscal accountability, quality control,
and professional and collegial control.

Importance of Controlling
DIRECTING - Helps in achieving the goals of the organization
- Ensures efficient and effective use of
- It is the manner of delegating
organizational resources for achieving the goals
assignments, orders and instructions to
- Helps in judging accuracy of standards
the nursing personnel. It is the KEY or
- Checks mistakes and tells how new challenges
HEART of management process.
can be met or faced
- The element of directing include
- Improves employee motivation
o Supervision - Ensure order and discipline
▪ Direct (when you’re present on work - Ensures the activities in an organization are
area directing. Observing staffs works) performed according to plans.
▪ Indirect (you have shared - Facilitates coordination in action
responsibility, you’re easy to contact - Reduces/eliminate risk of nonconformities
and available anytime when you’re - Helps in minimizing errors
needed) - Helps in improving performance
o Delegation - Correct deviations
o Communication, teamwork and collaboration
o Problem-solving and decision-making Control Includes
o Conflict management and change - Policies
management. o Broad guidelines for the managerial
o Motivation decisions that are necessary in
organizational and departmental
planning
Importance of Directing
- Rules
- Establishes direction in carrying out desired o Set of understood regulations or
action. principles governing conduct within a
- Integrates effort particular activity or sphere.
- Enables employee to cope with changes
NURSING PRACTICE AND LEGAL ASPECTS IN
LEADERSHIP AND MANAGEMENT
NURSE PRACTICE ACT
1. A nurse practice act is a series of a statutes
that have been enacted by each state legislature
to
regulate practice of nursing in that state.
2. Nurse practice acts set educational
requirements for the nurse, distinguish between
nursing
practice and medical practice and define the
scope of nursing practice
3. Additional issues covered by nurse practice
acts include licensure requirements for
protection of
the public, grounds for disciplinary action, rights
of the nurse license if a disciplinary action is
taken, and related topics
4. All nurses are responsible for knowing the
provisions of the act of the state or province in
which
they work.
STANDARDS OF CARE
1. Standards of care are guidelines that identify
what the client can expect to receive in terms of
nursing care.
2. The guidelines determine whether nurses
have performed duties in an appropriate
manner.
3. If a nurse does not perform duties within
accepted standards of care, the nurse places
himself in
jeopardy of legal action
4. If a nurse is named as defendant in a
malpractice lawsuit and proceedings show that
the nurse
follower neither the accepted standards of care
outlined by the state or province nurse practice
act nor the policies of the employing institution,
the nurse’s legal liability is clear;
EMPLOYEE GUIDELINES
1. Respondent Superior: The employer is held
liable for any negligent acts of an employee if the
alleged negligent act occurred during the
employment relationship and was within the
scope of
the employee’s responsibilities.
2. Contracts
a. Nurses are responsible for carrying out the
terms of a contractual agreement with the
employing agency and the client
b. The nurse-employee relationship is governed
by established employee handbook and client
care policies and procedures that create
obligations, rights and duties between those
parties.
3. Institutional Policies
c. If the nurse practices nursing according to
client care policies and procedures established
by
the employer, functions within the job
responsibility, ad provides care consistently in a
nonnegotiable manner, the nurse minimizes the
potential for liability
REMINDER!
The nurse must follow the guidelines identifies in
the nurse practice act and agency policies and
procedures when delivering client care.
HOSPITAL STAFFING
1. Charges of abandonment may be made
against nurses who “walk out” when staffing is
inadequate
2. Nurses in short staffing situations are
obligated to make a report to the nursing
administration.
FLOATING
1. Floating is an acceptable, legal practice used
by health care facilities to alleviate the
understanding and overstaffing.
2. Legally, a nurse cannot refuse to float unless a
union contract guarantees that nurses can work
only in a specifies area or the nurse can prove
lack of knowledge for the performance of
assigned tasks.
Floating nurse – mga hinihila sa ibang area kapag
kulang staff
3. Nurse in a floating situation must not assume
responsibility beyond their level of experience or
qualification
4. Nurses who float should inform the supervisor
of any lack of experience in caring for the type of
clients on the new nursing unit
DISCIPLINARY ACTION
1. Board of nursing may deny, revoke, or
suspend any license to practice as a registered
nurse,
according to their statutory authority
2. Some causes for disciplinary action are as
follows:
a. Unprofessional conduct
b. Conduct that could affect the health
and welfare
c. Failure to use sufficient knowledge,
skills or nursing judgement
d. Physically or verbally abusing a client
e. Assuming duties without sufficient
preparation
f. Knowingly delegating to unlicensed
personnel
g. Failure to maintain an accurate record
for each client
h. Falsifying a client’s record
i. Leaving a nursing assignment without
properly notifying appropriate
personnel
RISK MANAGEMENT
Risk management is a planned method to
identify, analyze and evaluate risks, followed by
a plan for reducing the frequency of accidents
and injuries.
Programs are based on a systematic reporting
system for unusual occurrences.
INCIDENT REPORTS
- The incident report is used as a means of
identifying risk situation and improving client
care
- Follow specific documentation guidelines
- Fill out the report completely, accurately, and
factually
(Incident report is given to the office, it is not
placed in the pt chart/record)
- The report form should not be copied or placed
in the client’s record
- Make no reference to the incident report form
in the client’s record.
- The report is not a substitute for a complete
entry in the client’s record regarding the
incident.
- If a client injury or error in care occurred, assess
the client frequently.
INCIDENTS THAT NEED TO BE REPORTED
- Medication administration errors
- Needle-stick injuries
- Procedure-related or equipment-related
accidents
- A visitor injury that occurred in the health care
agency premises
- A visitor who exhibits symptoms of a
communicable disease
SAFEGUARDING VALUABLES
Client’s valuable should be given to a family
member or a secured for safekeeping in a stored
and locked
designated location, such as the agency’s safe;
the location of the client’s valuables should be
documented per agency policy.
Many health care agencies require a client to
sign a release to free the agency of the
responsibility for
lost valuables.
A client’s wedding band can be taped in place - Route of Administration
unless a risk exists for swelling of the hands pr - Frequency of administration
fingers. - Physician’s or health care provider’s signature

Religious items, such as medals or scapulars, may DOCUMENTATION

be pinned to the client’s gown if allowed by - Documentation is legally required by
agency accrediting agencies, state licensing laws, and
policy. state nurse
and medical practice acts.
DOCUMENTATION - The nurse should follow agency guidelines and
Documentation Guidelines: Narrative and procedures
Information technology
- Document care, medications, DOCUMENTATION GUIDELINES: NARRATIVE
treatments, and procedures as soon as AND INFORMATION TECHNOLOGY
possible after completion - Use black-colored ink pen for narrative
- Document client responses to documentation
interventions - Date and time entries
- Document consent for or refusal of - Provide objective, factual, and complete
treatments. documentation
- Use quotes as appropriate for subjective date
PHYSICIAN’S PRESCRIPTION - Use correct spelling, grammar, and
- A nurse is obligated to carry out a physician’s punctuation.
prescription (order) except when the nurse - Avoid unacceptable abbreviations.
believes a prescription to be inappropriate or - Avoid judgmental or evaluative statement such
inaccurate as “uncooperative client”
- A nurse carrying out an inaccurate prescription - Do not leave a black spaces on documentation
may be legally responsible for any harm suffered forms
by the client. - Use only the user identification code, name, or
- The nurse should clarify with the physician an password for computerized documentation.
unclear or inappropriate prescription - Never lend access identification computer
- If no resolution occurs regarding the codes to another person; change password at
prescription in question, the nurse should regular intervals
contact the
nurse manager or supervisor. CLIENT AND FAMILY TEACHING
- The nurse should follow specific guidelines for - Provide complete instructions in a language
telephone prescriptions. that the client or family can understand
- The nurse should ensure that all components of - Document client and family teaching, what was
a medication prescription are documented taught, evaluation of understanding and who
was present during the teaching
COMPONENTS OF A MEDICATION - Inform the client of what could happen if
PRESCRIPTION (ORDER) information shared during teaching is not
- D ate an time order was written followed.
- Medication name
- Medication dosage
REMINDER!
The nurse should never carry out a prescription
if it is unclear or inappropriate. The physician
should be
contacted immediately
LAWS
- Nurses are governed by civil and criminal law in
roles as providers of services, employees of
institutions, and private citizens.
- A nurse has a personal and legal obligation to
provide a standard of client care expected of a
reasonable competent professional nurse.
- Professional nurses are held responsible (liable)
for harm resulting from their negligent acts or
their failure to act.
TYPES OF LAWS
1. CONTRACT LAW
- Contract law is concerned with enforcement of
agreements among private individuals
2. CIVIL LAW
- Civil law is concerned with the relationships
among persons and the protection of a person’s
rights. Violation may cause harm to an individual
or property, but no grave threat to society
exists.
3. CRIMINAL LAW
- Criminal law is enforced with relationships
between individuals and governments, and with
acts
that threaten society and its order; a crime is an
offense against society that violates a law and is
defined as misdemeanor (less serious nature) or
felony (serious nature)
4. TORT LAW
- A tort is a civil wrong, other than a breach in
contract, in which the law allows an injured
person
to seek damages from a person who caused the
injury
NEGLIGENCE AND MALPRACTICE
- NEGLIGENCE is conduct that falls below the
standard of care
- Negligence can include acts of commission and
acts of omission
- A nurse who does not meet appropriate
standards of care may be held liable
NEGLIGENT ACTS
- Medication errors that result in injury to the
client
- Intravenous administration errors such as
incorrect flow rates or failure to monitor a flow
rate that results in injury to the client.
- Falls that occur as a result of failure to provide
safety to the client
- Failure to use sterile technique when indicated
- Failure to check equipment for proper
functioning
- Burns sustained by the client as a result of
failure to monitor bath temperature or
equipment
- Failure to monitor client’s condition
- Failure to report changes in the client’s
condition to physician
- Failure to provide a complete report to the
oncoming nursing staff
MALPRACTICE IS NEGLIGENCE ON THE PART OF
A NURSE
- Malpractice is determined if the nurse owed a
duty to the client and did not carry out the duty
and the client was injured because the nurse
failed to perform the duty.
PROOF OF LIABILITY
a. DUTY: At the time of injury, a duty existed
between the plaintiff and the defendant
b. BREACH OF DUTY: The defendant breached
duty of care to the plaintiff.
PROFESSIONAL LIABILITY
- Nurses need their own liability insurance for
protection against malpractice lawsuits
- Having their own insurance provides nurses
protection as individuals; this allows a nurse to
have
an attorney present who has only the nurse’s
interests in mind.
CONTROLLED SUBSTANCES
- The nurse should adhere to facility policies and
procedures concerning administration of
controlled substances, which are governed by
federal and state laws.
- Controlled substances must be kept locked
securely, and only authorized personnel should
have access to them.
GOOD SAMARITAN LAWS
- Immunity form suit applies only when all
conditions of the state laws are met, such as the
healthcare provider receives no compensation
for the care provided and the care given is not
intentionally negligent.
RECORDS MANAGEMENT
Record
- Permanent written communication that
documents information relevant to a
client’s healthcare management.
- Clinical, scientific, and administrative
and legal document relating to the
nursing care given to the individual
family or community.
- Ex. Client chart
Records Management
- Systematic and effective control of
records (paper, electronic) throughout
their life cycle from creation or receipt
through to the time of their disposal.
Importance of record management
- Unless records are managed efficiently it
is not possible to conduct business, to
account for what has happened in the
past, or to make decision about future.
- To provide evidence of actions and
decisions
- To support accountability and
transparency
- To comply with legal and regulatory
obligations, including employment,
contract and financial law, as well as the
Data Protection Act and Freedom of
Information Act.
- To support decision making.
- To protect and interest of staff, students
and other stakeholders
- Help to address complaints or legal
processes, including requests from
patients under subject access provision
of the Data Protection Act or other
requests under the Freedom of
Information Act.
- To support day-to-day business which
underpin the delivery of care
- To support evidence-based clinical
practice
 - To assist clinical and other types of
audits
- To support sound and administrative
and managerial decision-making, as part
of the knowledge-base for NHS services.
- To support improvement in clinical
effectiveness through research and also
to support archival function by taking
account of the historical importance of
material and need of future research
- Record-keeping procedures and
processes should cover all types of
patient activity where data is collected
onto relevant system and paper-held
records.
Benefits of Record management
- Saves time by ensuring that records can
be found easily and quickly
- Saves space by preventing records from
being kept longer than necessary
- Saves money by reducing storage cost
and maintenance costs
- Improves efficiency by ensuring records
are readily accessible
- Improves compliance by keeping
records in line with legal and regulatory
requirements.
PURPOSE OF RECORDS
- Provides staff member, administrator,
and other health team members with
essential with essential data for program
planning and evaluation.
- Serves as tools from communication
between health workers, the family and
other development personnel.
- Provides data to forecast the long-term
changes for service improvement.
NURSING OFFICE RECORDS
- Its under or within department (Nursing
service office)
Personal Record (Form201)
- Personal data, physical examination,
performance ratting evaluation,
references, achievement, staff and
professional activities and confidential
information.
Master Staffing Pattern
- Daily assignment of nursing personnel
which will help the Chief Nurse visualize
the converge of all nursing units, serving
as a guide and support fir proposing
additional positions in the Nursing
Service.
Ex: Master Unit Plan (ginagawa ng chief nurse
kung sino naka assign sa OR, ilan yung patient)
General ward 1:12
Special ward 1:3
The Daily Census of Patient
- Detailed list of actual patients in the
difference in-patient and the total
census for 24 hours.
The Daily Time Record or Bundy Clock
- These indicated the time each personnel
reported to and from duty.
Nursing and Hospital Policies
- All directives affecting the Nursing
Service are compiled in a loose leaf
manual which is available for reference.
- Policies, admissions, discharges,
transfers for regulation, time and work
schedules, charging of patients etc.
- Directives are dated and signed by the
sender.
Manual of Procedure
- Set of standards operating procedures
for carrying out oral/telephone orders
medications, errors in medication,
omission of treatment, preventive
measures, such as (use of side rails and
restraints) arrangement of the patient’s
clinical charts, transcribing doctor’s
orders.
Minutes of Nursing Service Meetings
- Minutes of meeting within the Nursing
Service Manual are kept on file for ready
reference. Policies, rules and regulations
are discussed for weakness of
interpretation and implementation.
Nursing Affiliation record (for training and
teaching hospital)
- The school college folder contains
approved affiliation contract with the list
of students including the date and time
for affiliation and the clinical instructors.
- Record payments provides the number
of students; date and length of
affiliation; and payments each with
corresponding receipt number and
dates such were paid.
- Quarterly report of Affiliation
- Performance Evaluation record of
affiliation.
Records of Staff Development Programs
conducted
- Outreach program
- On-the -job training
- Nursing Leadership and Management
training
- Continuing Education Program
- Record of Nursing Researchers
conducted
- Continuous quality Improvement
Program conducted by Nursing
Importance of Recording and Reporting
- Measure, monitors and controls to
enhance the workforce performance.
- Improves communication among
managers, subordinates, customers and
other stake holders.
- Sets benchmark for quality
improvement of services.
Principles of Record Writing
- Nurse should develop their own method
of expression and form in record writing.
- Records should be written clearly and
appropriately.
- Records should contain facts based on
observation, conversation and action.
- Select relevant facts and the recording
should be neat, complete and uniform.
Ex. Morning (Black ink/ blue ink of ball pen)
- Record should be written immediately
after an interview.
- Records are confidential documents.
Nurses Responsibility for Record Keeping and
Reporting
- Keep under safe custody of the nurse
- No individual sheet should be separated
- Not accessible to patients and visitors
- Strangers is not permitted to read
records
- Records are not handed over to the legal
advisors without written permission of
the administration
- Handed carefully, not destroyed
- Identifies bio-data of the patients such
as name, age admission number,
diagnosis etc.,
- Never send outside the hospital without
written administrative permission.
Characteristics of Good Recording and Reporting
Accuracy Up-to-date Objectivity
Consciousness Organization
Thoroughness Confidentiality
Importance if Record in the Hospital
For the individual and family
- Serve the history of the client
- Assist in the continuity of care
- Evidence to support if legal issues arise
- Assess health needs, research and
teaching
FOR THE DOCTOR
- Serve the guide for diagnoses,
treatment, follow up and evaluation
- Indicate progress and continuity of care
- Self-evaluation of medical practice
- Protect doctor in legal issues
- Used for teaching and research
FOR THE NURSES
- Document nursing service rendered’
- Planning and evaluation of service for
future improvement
- Guide for professional growth
- Communication tool between nurse and
other staff involved in the care
- Indicate plan for future.
REQUIRED PATIENT’S DATA THAT NEEDS TO BE
DOCUMENTED
Admitting Area- ER/ OPD
- Admission date, time, room/bed
number of patient.
- Mode of admission, such as ambulatory,
by wheelchair, by stretchers etc.
- Vital signs/ height/ weight
- Admission notes
- Admitting physicians
- Written orders, prescriptions,
medication given
- Lab test
- Status of patient during transfer
In- Patient Areas
- Time of doctor’s visit and all subsequent
visits of the physician
- Written orders of all the physicians
- Subjective/objective observation
- Medications
- Diet
- Transfer
- Nursing care rendered
- Completion of day’s charting at midnight
as to time, date and calendar hospital
date
- Use of blue ink for am, red for night shift
REPORTS
- Verbal or written informational work in
particular matter made with an
intention to relay events, situations in a
presentable manner for decision making
- It can compiled daily, weekly, quarterly,
annually.
Sentinel Events
Occur when a patient is seriously injured
(permanently or temporary) or cause death,
happening outside the predictable course of the
patient’s disease process.
Anecdotal Report
A brief description of an observation behavior
that appears significant for evaluation purposes
Ex. Observation done by the Nurse supervisor
during clinical rounds
Incident Report
Problem occurred in nursing care delivery
Non-judgmental, factual, consequences
IR are simply records of all events that are not
part of routine medical care.
Change of shift reports- Oral, nursing rounds
Telephone Report/ Orders
Transfer reports (proper coordination)
NURSING DOCUMENTATION A-Action
- Nurse are required to make and keep Describes the nursing intervention
records of their practice (independent, basic and perspective) past,
- A self-regulated professionals, nurses present and future
are accurate and meets the Standards of
Documentation and Standards of R- Response
Practice. Describes the patients outcome/response to
- Nursing Act of 2002 and RA 9173 intervention or describes how the care plan
goals have been attained.
PURPOSES OF DOCUMENTATION
Communication NURSING KARDEX
Education - A medical information system used by
Research nursing staff.
Legal and Practice Standards - Way to communicate important
Professional Responsibility information on their patients.
Accountability - Quick summary of individual patient
Reimbursements needs that is updated at every shift
change.
GENERAL GUIDELINES FOR PROPER CHARTING - Physicians order which is already carried
- Consistent with policies out
- “anything that is not written is not done” OBJECTIVES
- Do not erase an error or remove pages, - Personal date
draw a line thru the error, note, it was - Physicians orders
mistaken entry and initial it - Medications
- Clear, legible, accurate, use proper - Treatment
terminology - Procedures
- Chronological at the time of occurrence - Intravenous therapy
- Ink followed, signed appropriately - Laboratory and other diagnostic
- Allergies
F-DAR CHARTING (FOCUS) - Diet
- Method of charting nurses use, along
with other disciplines, to help focus on a
specific patient problem, concern or
event
- Geared to save time and decrease
duplicate charting

F- FOCUS
Establish a focus of care, to be addresses in the
progress note

D-Data Subjective and/or objective information

supporting the stated focus or describing the
observation at the time of significant event.