REPORTING

 

INTRODUCTION

 

          Good health care administration depend upon the good reports.  Reports are good tool or vehicle for transmitting.  Information from downward to upward and upward to downward communication.  Reports are oral or written exchange of information shared between care givers or workers in a number of ways.

PURPOSES OF REPORTS

 

        Ideally the reports are written for following purposes.

 

Ø     To show the kind and amount to services rendered over a specified period.

Ø     To illustrate progress in reaching goals.

Ø     As on aid in studying heath condition.

Ø     As an aid in planning.

Ø     To interpret the services to the public and to the other interested agencies.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLASSIFICATION

Reports may be classified as oral and written.

1.    ORAL REPORTS

Oral reports are given when the information is for immediate use and not. For permanency for example oral report is made by the nurse who is assigned to patient care to another nurse who is planning to relive her. And some oral reports may be made to charge horses and nurse supervisors and also doctors.    

2.    Reports are to be written when the information is to be used by several personnel. Which is move or less of permanent value for example: day and night reports census interdepartmental reports and other special reports needed. according to situation events and conditions. The reports user in hospital setting usually are.          1.change of shift reports, 2.transfer reports,3. incident reports, day veining and night reports, 4.legal reports change of shift reports these may be given orally in person by audio toping recording or during rounds at the dent’s bedside some of the points to be kept in mind while giving such reports are follows.

·        Provide only essential background information about client    (name sex age diagnosis and medical history) but do not review all reciting cove procedure ore tasks 

·        Identify clients nursing diagnosis or health core problem and other related causes but do not review all biographical information on case sheets.

·        Shore significant information about family members, as it relates to client’s problems do not make any assumption about relationship between family members.

·        Ruby to start significant changes in the way therapies are given do not describe basic steps of a procedure.

·        Describe instruction given in teaching plan and clients response do not explain detailed content unless start member ask for clarification.

·        Be clear on priorities to which oncoming start must attend do not force oncoming start to guess what to do first.

 

TRANSFER REPORTS: 

              Patients will frequently be transferred form one unit to another to receive different levels of care a transfer report involves communications of information about clients form the nurse on sending. Unit to the nurse on the receiving unit when giving transfer request horse should include the following information.

 

Ø     Client’s name age primary doctor and medical diagnosis

Ø     Summary of medical progress up to the time of transfer

Ø     Current nursing diagnosis on problems and care plan

Ø     Needs for any special equipment etc   

 

INCIDENT REPORTS:

              Nurses usually become involved in client-reacted incidents as some point in their careers. They must understand the purpose of incident reports and correct way to report information while incident reporting the following points are to be kept in mind.

 

Ø     The nurse who witnessed the incident or who found the client at the time of incident should file the report   

Ø     The nurse describes in concise what happened specifically objective terms etc.

Ø     The nurse dose not interpret of attempt to explain the cause of the incident

Ø     The nurse describes objectively the clients condition when the incident was discovered

Ø     Any measures taken by the nurse other nurse or doctors at the time as the incident are reported

Ø     Do nurse is blamed in an incident report

Ø     The report is submitted as soon as possible to the appropriate authority

Ø     The nurse should never make photocopy of the incident report

 

LEGAL REPORTS:

              Incidents reports and reports on accidents mistakes and complaint are legal in nature there are times when a hospital is criticized for what is clamed to be negligence or poor care because as a condition that resulted in discomfort and partners serious harm to a patent or dent in such report the content is stated briefly and objectively giving all pertinent information accuracy timeliness completeness and relevancy to the problems are maintained promptly while making such reports.

 

NURSES REPONSIBILITY FOR KEEPING REPORTS

 

              Nurses have legal responsibility for accurately reporting patient conditions treatment and response to care generally the person who makes report required by statute is immune from suits under the doctrine of public’s right to know.

              Reports must be functional accurate complete current organized and confidential.

 

Fact

              Information about clients and their care must be functional.  A record should contain descriptive objective information about what a nurse sees, hears, and feel in the same way anything happens during the managing affairs in the institutions / hospital.

 

Accuracy:

              A client report must be reliable in other words information must be accurate so that the health team members have confidence in the use of correct measurements ensures that a report is accurate.

 

Completeness

              The information  within a report should be complete, containing conscience and through information about a client or any event or happening taking place in the jurisdiction of manager.

 

Correctness

              Delays in reporting can result in serious omission 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 format or order.  Health team members understand information better when it is given in the order in which it occurred.

 

CONCLUSION

 

              Good health administration depend upon the good reports, reports must be functional accurate, complete current organized and confidential.  The report summarizes the services of the person or personnel and as the agency.

 

BIBLIOGRAPHY

 

1.                B.T.Basavanthappa, Nursing Administration, J.P. Publishers, page No.146-159.

2.                H.A.Goddard’s Text Book of Principles of Administration applied to Nursing Service, Page.No.53.