DOCUMENTATION,
NURSING ROUNDS, MANUAL
& PROTOCOL
RECORDS
Records
are
administrative
formally
tools
permanently
legal,
that
document
information relevant to direct or
indirect patient care.
PURPOSES OF RECORDS
It provides an accurate and detailed account of treatment and care given to the
patient.
They evaluate quality patient care
They can be used as a reference material for research
Records are tools of communication among the health care team members
Records also have a legal value. The records safeguard the patients, nurses,
doctors and the hospital. It serves as evidence that the patient care is
intelligently managed.
They help the nursing and medical students in their clinical experience and
provide data for care studies.
PURPOSES OF RECORDS
It serves as a follow up of the course of the disease and future care
A record of illness and treatment saves duplication of work in the future care
especially when the patient is transferred from one department to another or
from one institution to another or when an attending physician is transferred
or other personnel takes charge.
The patients record, registers and reports furnish the vital statistics and give
information needed to evaluate the health care services rendered by the
hospital to the community.
Data taken from the patients record points out the health problems of the
country and it also provides a baseline in which local, state, national and
international health services can be planned.
TYPES OF RECORDS
Report book
Treatment book
Duty roster for staff
Stock register
Admission and discharge book
Complaint book for maintenance and
and respiration
Indent register
Reports of laboratory examinations
Diet register
Consent form for operations and
anesthesia
repairs
Graphic charts of temperature, pulse
Records
of
anesthesia,
physiotherapy, occupational therapy
and other special treatments
Physicians order sheets
REPORTS
A report consists of oral or written exchanges of
information shared between members in the health care
team.
A report is a system of communication aimed at
transferring essential information necessary for safe and
holistic patient care.
PURPOSES OF REPORTS
To communicate progress of the patients health status to all nurses in
different shifts
To prepare staff members for their days work
To ensure that all the staff members have the same information
To maintain continuity of care from one shift to another
To illustrate progress in reaching goals
To coordinate care among various health care personnel
To promote accuracy in the provision of quality care and prevent errors
To effectively manage time and avoid duplication or overlapping of activities
TYPES OF REPORTS
Reports among the members of the health team
Each member of the nursing team gives a detailed report to the team leader/
staff in- charge at the end of the shift. A report is given when the responsibility
for patient care is turned over from one person to another
Reports between the head nurse and her assistant
Reports between the head nurse and the nursing superintendent
The day, evening and night reports are sent to the nursing superintendent at
regular intervals. This includes the reports of all seriously ill patients, the
newly admitted patients, patients who had surgery, patients who had accidents,
census etc. the report may also contain the problems that are met with the
patient care. E.g. inadequate supply of articles.
TYPES OF REPORTS
Reports to the physician
The nurses provide report of any unusual changes in the patients
condition like medication side effects, results of any investigations etc.
Reports on accidents, mistakes and complaints
A detailed report on mistakes, accidents and complaints is sent to the
concerned authority such that such incidents are prevented in the future
and there is improvement in patient care.
NURSING ROUNDS/VISITS
Nursing
conducted
rounds
by
the
are
head
nurse/ nurse teacher with
her staff members/ students
for a clear understanding of
the disease and the effect of
nursing
patient.
care
for
each
PURPOSE OF NURSING ROUNDS/VISITS
To assess the physical and mental condition of the patients and
the progress made each day.
To observe the work of staff
To make specific observations of patients e.g. wounds, drainage,
bleeding etc.
To introduce patients to the staff members i.e. the patients
history, treatment and all the medical aspects of his care.
To formulate a plan of action for care of patients
PURPOSE OF NURSING ROUNDS/VISITS
To evaluate the results of treatment and patient satisfaction
To ensure that safety measures are employed for patients and personnel
To orient the staff nurse/ nursing students towards the health status of their
patients
To teach nursing students and hospital staff regarding specific conditions
To initiate any modifications in nursing action
To ensure the safety and working condition of the equipments kept in the
patients bedside
ADVANTAGES OF NURSING
ROUNDS/VISITS
They offer a real life learning situation to both student nurses
as well as staff
It helps in the evaluation of nursing activity
They help in orienting a staff nurse/ student nurse to the
patient
The hurdles faced by nurse in implementing treatment can be
resolved
To evaluate the nursing care and level of satisfaction among
patients
DISADVANTAGES OF NURSING
ROUNDS/VISITS
The confidentiality of the patient is hampered
Distractions are present in the ward
An unprepared nursing round has little teaching learning
value
It is not effective if the group is large
It may evoke undue anxiety in the patient when his/her case in
discussed.
NURSING MANUALS
It is the compilation of all the rules or guidelines
concerning the procedures or management of identified
problems which available for reference. The contents of
the manuals, particularly in relation to the specific
procedures are more acceptable if compiled following a
group discussion.
ADVANTAGES
They
specify
the purpose for
which
the
procedure is to
be used, the
equipment
needed,
the
sequence
of
steps in the
procedure and
the precautions
to be observed.
The standards
of performance
are ensured
Helps in the
provision
of
safe
and
effective care
with available
resources and
personnel
DISADVANTAGES
If the manuals are not revised periodically,
faulty and old practices may continue.
NURSING PROTOCOLS
Protocols are written instructions for caregivers to follow when individuals
have specific or frequent problems from a health concern that usually has a
predictable outcome. Protocols give guidance to caregivers on signs and symptoms to
looks for, when and how to intervene and who to notify.
Protocols are sometimes confused with procedures. Procedures are task oriented. They
provide step-by-step instructions on how to do a task. For example: how to administer
a gastrostomy feeding or how to empty a Foley catheter bag.
Standing orders are specific instruction regarding treatment for condition that nurses
and other health workers may encounter in home, school and industries where a doctor
is not readily available. The standing order are intended to provide treatment only in
emergencies and temporarily in the absence of a doctor, they should be limited.
PURPOSE
To promote health services in community
To provide temporary treatment in the
absence of a doctor
To deliver
community
care
at
home,
school,
To meet emergency situation in rural area
TYPES OF STANDING ORDER
1.
Institutional standing orders
They are kept keeping in view the available resources, staff position and the objectives of a
medical institution or hospital. E.g. Standing orders of primary health centers can be different from
those of district hospitals.
1.
Specific standing order
These orders are meant for trained medical personnel, mainly the nurses. Technical knowledge
and specific skills are required to implement these orders. E.g. giving care at home, injections,
oxygen therapy etc.
1.
General standing orders
Owing to a large population, vast geographical area and the shortage of resources, some standing
orders are used to propagate health care messages to the masses. E.g. preventive measures against
AIDS etc.
ADVANTAGES OF STANDING ORDERS
They help to strengthen the primary services in the
community
They help to decentralize the health responsibilities
They provide a feeling of confidence and responsibility in
the nursing staff and other health workers
They enhances the quality and activity of health services
Community standing orders provides timely treatment
during emergencies
