DR / AMANY LOTFY abd alaziz

professor of med .sur nu

Faculty of nursing – Tanta
university
Outlines
Introduction -1
I
– mportance of reports and records 2 
.Reports -3
a) oral reports 
b) Written reports 
:Guideline for written report– 4
Records ]11
-: kinds of records 
a) records used in nursing unit
B ) records used in nursing office
Introduction
Reports and records are important 
system in every health care
organization. It organized to render
service to the patients by health
care providers,and
care providers, andhospital
hospital
administration.
.administrationThe kind and
amount of service rendered in the
hospital depends on the accuracy of
.information in reports and records
purposes of reports and 
:records

provide a way of communication )1

among the health care providers
.who contribute patient care
Used as documentary evidence )2 
of the course of the patient's
illness and treatment during
.hospitalization
Serve as a basis for analysis, )3 
study and evaluation of the quality
.of care rendered to patient
Provide clinical data for research )4 
.and education
Provide continuity of patient )5 
care
Serve as a basis of planning )6 
.individual patient care
Assist in protecting the legal )7 
interests of the client, health
organization, and health care
.providers

.Reports 
Report is a document form 
which include ; conclusions or
findings based on facts, or
.recommendations concerning them
Reports should be clear, concise 
.and accurate
The supervisor and head nurse 
responsibility to instruct personnel
how using all forms
:A)oral reports 
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 to the
physician , supervisor, etc
:B) Written Reports 
:It includes 
Day, evening and night-1 
.report
.Incident report-2 
. Report of complain-3. 
Report including-4. 
.negligence
.Reports for requisition-5 . 
Day, Evening and -1 
:night report
Are written summaries of patient's 
information about their condition and
activities
activitiesthat
thatrelated
relatedto
totheir
theircare
care-as:
:as-
.patient census
All
Allacutely illand post - operative - 
acutelyill
.patient
Patients with and change in general - 
condition, e.g. vital signs or those who
.had special treatment
Admissions
Admissionsdischarges, transfersand - 
discharges,transfers
.deaths during the shift
Patients scheduled for operations or - 

.special investigations
:Incident report .2 
Any happening which is not consistent 
with routine of hospital operation or
patient care. It may be an incident or a
situation, which might result in an
accident , E.g..error on medication and
, accidentE.g
..., omission of the treatment
animportant administrative tool 
itit isisan
for use in studying cause of accident
in the hospital by providing
information which lead to effective
preventive measures and in case of
:Should include
.Patient's name and diagnosis -
Time of incident noted or -
.reported
.What was done -
Date and signature of -
individuals involved in the
incident
:Report of complain-3
Serious complaints , which cannot de
handled by the ward personnel , are
reported to the nursing office. The
: report should include
. Statement of complaint E.g. pain -
.Justification as seen by the nurse -
Measures taken to overcome the -
.dissatisfaction
.The result of action taken -
.Date and signature -
:Report for negligence .4
is a report including carelessness or
disregard of regulations on the part of a
member of the nursing personnel to the
.nursing office
:Reports for requisitions .5
Written requests for supplies equipment or
service to be sent from the unit to the
concerned department
Guideline for written 
:report
Have the patient's name and .1 
.hospital number on every sheet
initiate each entry with the date and .2 
.time
Chart after providing care, not .3 
.before
. Chart as soon and as possible .4 
Chart only your own observation, .5 
.care , and teaching
.Be objective in charting .6 
. 
Guideline for written report 
use only hard - pointed , .7 
. permanent black ink pens
be timely , specific , accurate , .8
.and complete
use concise phrase , begin each .9
phrase with capital letter and
.each new topic on a separate line
use only approved.10 
. abbreviations and medical terms
Guideline for written
report
use medical terminology only if. 11 
.you are sure of its meaning
follow rules of grammar and.12 
.punctuation
fill all spaces. Draw a horizontal.13 
.line in unused space
correct errors in documentation.14 
.as soon as possible
do not erase the error or use.15
.correction fluid
Draw a single line through any.16
erroneous information, write the words
"error " or "error in charting" above it
along with your name , and write the
.entry correctly
put entries in order of consecutive.17
.shifts and days
sign each block of charting or energy .18
with full legal name and title
:Records ]11‫ السجالت‬
Are administrative tools used
to classify and prevent
.duplication of the information

-An Administrative
Educational 
.Research objectives 


:Kinds of Records
a) records used in b) records used
nursing unit in nursing office
patient record-1 Master record of .1
assignment -2. . nursing hours
.record 
time record -3 attendance .2
.census record -4 .record
inventories-.5 personnel .3
. record
.record 
a. Employment
narcotics and -.6 , record
medication b. Evaluation 
record record
A) Records used in nursing 
:unit
:Patient record .1 
It is an orderly written form of 
patient condition, which include
findings, treatment and
patient's progress that provide
sufficient information about the
period of hospitalization and
.the care given
 Patient record 
:data of admission. includes 
.A- Admission and discharge records 
.B- Medical and physical examination 
. C- Medical progress notes 
D- Physician orders 
E- Graphic records as temperature , 
... intake and output, etc
. F- Vital signs record 
. G- Medication administration record 
. H- Discharge plan 
Nurse's notes AS an 
example of pt.record should
:include
Date, time and manner of - 
admission (wheel chair crutches ...)
Statement of apparent condition of -
.the patient
.Record of symptoms noted -
.Treatment - 
.Time and type of specimen -
Signature should include full name -
Importance of nurses
:notes
Provide an accessible form -
.followed by nurses
Transfers responsibility from -
.the nurse to other
Makes it possible to review -
readily and quickly the patient's
Other records as anesthesia -
records, radiology, and x-ray
...test, etc
Assignment .2
:records
Are records containing the 
assigned duties for each nursing
staff member. 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 - 
:Importance of this record
To inform nursing staff in writing -
about the patient for whose nursing
.care and for special assignment
To maintain for fixing -
. responsibilities for nursing care
To evaluate the nursing care given -
and for discussing and conducting
. conference (on duty conference)
:Time schedule record .3 
It is a weekly or monthly record, 
which indicates the planned coverage
of nursing personnel for each nursing
unit. The form should include
name of all categories of nursing - 
personnel on the unit
days off and vacations and - 
the various categories of personnel 
being groups for a week or for 24
.hours
Purpose of time schedule
:record
shows the coverage for -
the unit
Records the presence and - 
.absence of nursing personnel
Give information about -
service rendered
:Patient census record .4
it is a daily record for each unit
from which the official patient
.census of the hospital is derived
The unit clerk under supervision
of the head nurse. The form
includes; number of beds in the
unit and sent to the proper
.administrative offices
:Inventory record

It is a form used for .4

recording all articles of
.furniture
Equipment and instruments
with the received date, and
quantity of each element of
.articles
Importance of the 
:inventory record
Provide head nurses with - 
information upon which to request
replacements needed either
.because of loss or breakage
Identify and replace the - 
missing items, and all borrowed
.articles are returned
b) Records used in nursing 
:office
Master record of nursing .1 
:hours
This record derived from the 
time schedule records of the
nursing units and should show
the distribution of the hours for
each nursing personnel in the
.hospital
:Attendance record .2
:Personnel record .3
It is concerned with information
about each individual nurse ,
assembled in a file , which
: includes
.copied application -
.Photograph -
Basic nursing education and -
professional preparation
.Evaluation records -


This records should be the

responsibility of the
assistant director for
personnel in the nursing
.office
The personnel record
:consists of
a. Employment record 

:includes
.Position on employment - 
.Professional preparation- 
.Registration number- 
.Date of employment- 
.Date of promotion- 
Date and reasons for termination of- 
.employment
Summary of nurse's achievement,- 
.weaknesses and recommendations
:b. Evaluation record
It is filled periodically for all nursing
personnel and indicates professional
progress of the nurse. Importance of
:evaluation records
an objective basis on which to base -
.personnel promotion
.An incentive to individual progress -
Provides reason for poor performance -
The areas for evaluation that 
need to be included in the record
:are
Nursing abilities, efficiency and quality of .1 
.performance
Attitudes and relationships with patients, .2 
.workers and supervisors
Attitudes towards and achievement of self .3 
.development
Represent the opinion of more than one-4 
.supervisor
 - Match the following from column A to column B (5
marks):
Answer
Term Definition
Inventory record -1 a-record containing
the assigned duties
for each nursing staff
.member
Patient census -2 b-its weekly or
record monthly record
Assignment record -3 c-is an orderly written
form of patient
condition
Time schedule -4 d- It is a form used for
record recording all articles
.of furniture
Patient record -5 e- Daily record which
1 2 3
the 4official5 census of
the hospital is
Final Questions
Why are reports and records essential in .1 
?nursing

.List three guidelines for written reports .2 

Differentiate between oral and written .3 

.reports

What are the key purposes of patient .4 

?records

.Explain the significance of incident reports .5 

E-Learning course
activities
List types of records &
reports used in nursing
? unites & nursing office