Records and Reports

Outlines
◼ -Importance of records and reports
Records
◼ Principles of records writing
◼ Values and uses of records
◼ Kinds of Records:
◼ Records used in nursing unit
◼ Records used in nursing office
Reports
◼ Purposes of Writing Reports
◼ Types of reports
◼ Oral Reports
◼ Written reports

◼ Summary for guideline for written report

 Records And Reports

◼ Records and reports are important system in

every health care organization. It 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:
1. Provide a way of communication
2. Used as documentary evidence of the course of
the patient’s illness and treatment during
hospitalization.
3. Serve as a basis for analysis, study and
evaluation of the quality of care rendered to
patient.
4. Provide clinical data for research and education.
5. Provide continuity of patient care on
subsequent admissions of the patient.
6. Serve as a basis for planning individual patient
care.
7. Assist in protecting the legal interests of the
client, health organization, and health care
providers.
 Principles of records writing
◼ Records should be written clearly, appropriately
and legibly.
◼ Records should contain facts based on
observation, conversation and action.
◼ Select relevant facts and the recording should be
neat, complete and uniform
◼ Records are valuable legal documents and so it
should be handled carefully, and accounted for.
◼ Records systems are essential for efficiency and
uniformity of services.
◼ Records should provide for periodic summary to
determine progress and to make future plans.
◼ Records should be written immediately after
giving care.
◼ Records are confidential documents
 Values and uses of records
◼ Record provides basic facts for services.
◼ Provides a basis for analyzing needs in terms of
what has been done, what is being done, what is
to be done and the goals towards which means
are to be directed.
◼ Provides a basis for short and long term
planning.
◼ It prevents duplication of services and helps
follow up services effectively.
 Kinds of Records
(A) Records used in
nursing unit
1- Patient record
2- Assignment record
3- Time record
4- Census record
5- Inventories record
6- Narcotics and Medication
record
(b) Records used in
nursing office
1- Master record
2- Attendance record
3- Personnel record
◼ Employment record
◼ Evaluation record
 Patient record/ medical record

◼ To nurses, physicians, and other members of the

healthcare team, a medical record is usually an
accumulation of paper, reports, and
correspondence collected into some kind of
folder system. This file is the result of either
ongoing care over a period of time.
It includes:
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: are used by nursing personnel to record
the care provided and patient responses. They include
significant data on medication, treatment, diet, teaching,
recording of observations of physical and mental
condition of the patient, abnormal condition of skin, hair,
etc..
 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. 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.
list of special assignments.
Time schedule record:
 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.
 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.
 (B) Records used in nursing
office
◼ Master record of 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:
 Report
◼ is a document form which include; conclusions
or findings based on facts, or recommendations
concerning the patient. It aims to be transmit
valuable information to a person or a group of
persons.
◼ Reports should be clear, concise and accurate.
 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.
 Guideline for written report:

1. Have the patient’s name and hospital

number.
2. Initiate each entry with the data 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- 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.
 Unit Report (Statistical Report)
Name of unit: Name of the head nurse:

Date
PatientCensus Admissions Discharges Transfer Death Criticalpatient Total
Time
 Medication Record
Unit: Date: Number of
patients:
Patients' name Medication prescribed Remarks

Total
 Shift Report

◼ Date: Time of shift: Unit:

◼ No. of beds: Head nurse name: Patient census:

Room No.
Patients' name Diagnosis Summary of patients' condition
Bed No.
 Incident report form

◼ Unit name: Name of the head nurse

Patient name: age: sex:

Date of admission: Diagnosis:

Attending physician:
List of medication within 6 hours if permanent:
Type of incident:-

-Error in medication -Patient movement (Fall)

-Diagnostic procedure - Treatment-

Others
Date: Time : Shift:
Description of incident:

Name of first person or persons present at time of incident &professional status

Nursing interventions:

Date: Time: Sig :

Follow up:
Patient name: age: sex:

Date of admission: Diagnosis:

Attending physician:
List of medication within 6 hours if permanent:
Type of incident:-

-Error in medication -Patient movement (Fall)

-Diagnostic procedure - Treatment-

Others
Date: Time : Shift:
Description of incident:

Name of first person or persons present at time of incident &professional status

Nursing interventions:

Date: Time: Sig :

Follow up:

Sig :
 Nursing Progress Notes form
members&Mix:
Date: Unit: Head Nurse ◼
Name:
Team leader's name: No. of
patient:
No. of critical patient: No. of team
Time Patient Name Nurses Progress Note Signature
 Kardex
Diagnosis: Sex: Occupation: Age: Marital status:

Bed No.: Room No.: Hospital No.:

Date of admission: Date of operation:

Awareness Level: - Coma - Mentally Disturbed - Alert

Vital signs on admission:

- Temp: c - pluse: b/m - Resp: c/m - Bl.P: mmhg

Daily vital signs:

Temp: c - pluse: b/m - Resp: c/m - Bl.P: mmhg

Diet :

Elimination: - Urine: Stool:

Physical Condition: - Can walk - Walk with assistant - Bed ridden