Our memories are short

 

 

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.