All professional persons need to be accountable for the performance of their duties to be public
INTRODUCTION
Our
memories are short, and information collected from memory cannot be
reliable. Therefore, all the
employmental authorities enforces documentation of events. So the records and reports came into
practice. These are the effective means of
communication. Complete and concise
reports are vital for good management and administration. Record and reports have an enlightening place
in the hospital management and administration.
These are the important legal
documents to be maintained in the hospital settings.
DEFINITIONS
RECORD
A
record is a clinical, scientific, administrative and legal document relating to
the nursing care given to individual, family or community.
REPORT
Reports
are oral or written exchanges of information shared between caregivers or
workers in a number of ways.
PURPOSES OF RECORDS
·
Record provide data for
programme planning and evaluation.
·
Records are the tools of
communication between the health workers, the family and other evelopment
personnel.
·
Records indicate plans for the
future
·
Records provide baseline data
to estimate the longterm changes related to the services.
·
Records provide an opportunity
for evaluating the services.
·
Records help in the research
for improvement of nursing care.
PURPOSES OF REPORTS
·
To show the kind and amount of
services rendered over a specified period.
·
To illustrate progress in
reaching goals.
·
As an aid in studying health
conditions
·
As an aid in planning to
interpret the services to the public and to the other interested agencies.
TYPES OF RECORDS
·
The patients clinical record.
·
Records of nurses observations
Nurses notes
·
Records of orders carried out.
·
Records of treatment.
·
Records of admission and
discharge.
·
Records of equipment loss and
replacement.
·
Records of personnel
performance.
TYPES OF REPORTS
·
Oral reports: Oral reports are
given when the information is for immediate use and not for permanency.
·
Written reports: Written
reports are given when the information is to be used by several personal, which
is more or less of permanent value.
FILLING
OF RECORDS
Records should be arranged
a)
Alphabetically
b)
Numerically
c)
Geographically and
d)
With index cards
NURSES
RESPONSIBILITY FOR RECORD KEEPING AND REPORTING
Nurses
have legal responsibility for accurately reporting and recording patients conditions,
treatments and responses to care.
Record
and reports must be functional, accurate, complete, current organized and
confidential.
Functional
Information
about clients and their care must be functional, a record should contain
descriptive, objective information about what a nurse sees, hears, feels and
smells. In the same way any thing
happens during the managing the affairs in the institutions / hospital, manager
should document inferences or construct with functional information to avoid
misleading, misinterpretation and my error in administration.
Accuracy:
A
client record must be reliable. In other
words, information must be accurate so that health team members have confidence
in it. The use of correct measurements
ensures that a record is accurate.
Completeness
The information within a recorded
entry or a report should be complete, containing concise and through information’s
about a client care or any event or happening taking place in the jurisdiction
of manager.
Correctness
Delays
in recording or reporting can result in serious omissions and untimely delays
for medical care or action legally, a late entry in a chart may be interpreted on
negligence.
Organisation
The
nurse or nurse manager communicates information in a logical formal or
order. Health team members understand
information better when it is given in the order in which it occurred.
Confidentiality
Nurses
are legally and ethically obligated to keen information about clients illness
and treatments confidential.
IMPORTANCE OF RECORDS IN HOSPITALS
The
service of nursing personnel will be meaningful only when it is properly
recorded and maintained. Records have
the following advantages to the individual and family, the doctors, the nurse,
the authorities and also contribute to the education and research and health
planning.
For the Individual and family
The records help individual and family
to become aware of and of recognize their health needs under following
headings.
·
Records serve to document the
history of the client.
·
Records assist in the
continuity of care.
·
Records serve as an evidence to
support or to refute the legal questions that arise.
·
Records serve to recognize the
health needs and can be used as a research and teaching tool.
For the doctor
·
Records serves as guide for
diagnosis treatment follow up and evaluation of services.
·
Records indicate progress and
continuity of care
·
Records help self evaluation of
medical practice.
·
Records protect the doctor in
case of legal issues.
·
Records may be used for
teaching and research.
For the Nurse
·
The record provides with
documentation of services rendered.
·
Records provide data essential
for planning and evaluation of services for further improvement.
·
Records serve as a guide for
professional growth.
·
Records enable to judge the
quality and quantity of work done.
·
Records indicate plans for the
future
For authorities
·
Records provide the management
with statistical information necessary for decision in regard to utilization of
resources, planning for administrative control and future references.
·
Records furnish documentary
evidences for proposals of evaluation of care in terms of quality, quantity and
adequacy.
·
Record helps the administrator
assess the health assets and need of the community.
·
Records provide justification
of expenditure of funds.
·
Records help in making studies
for research, for legislative action and for planning budget.
CONCLUSION
All
professional persons need to be accountable for
the performance of their duties to be public. Since Nursing has been considered as
profession, nurses need to record, and report their work on completion.
BIBLIOGRAPHY
1.
B.T.Baswanthappa, Nursing
Administration, Jaypee Publishers, Medical [PVT] Ltd., page No.146-151.
2.
Colonel BM Skharkar, Principles
of hospital Administration and Planning, Jaypnee Brothers, Pg.No.
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