1. Application for Models for Organization and Guidelines for Contents Documentation system Application for Models for Organization and Guidelines for Contents 1- Source oriented record: the information about a patient's care and illness is organized according to the "source" of the information within the record, f it is recorded by the physician, the nurse, or data collected from an x ray or laboratory test are filed under their specific sectionalized areas in the chart usually in chronological order. Many facilities use this format since it is easy to locate documents.

2. For example, if a physician needs to reference a recent lab report, it can easily be found in the laboratory section of the record. However, if a physician wanted to reference all information about a particular diagnosis being treated or treatment given on a particular day, many sections of the record would have to be referenced making it difficult to amass all the information for that specific diagnosis difficult.

3. Each person or department make notations in a separate section or section of the client chart. Narrative charting is a traditional part of the source oriented record.

4. DisadvantagesAdvantages The information about the a particular client problem is scattered throughout the client chart. Convenient and easy to trace.

5. Cont ’ 2- problem oriented medical record : The data arranged according to the problem the client has rather than the source of the information. we will define problem as anything that interferes with the health, well being and quality of life of an individual, that may be medical, surgical, obstetric, social or psychiatric, The health team contribute to the problem list, plan of care and progress note.

7. Cont ’ DisadvantagesAdvantages a) Caregivers differ in their ability to use the required charting format. a) Encourages collaboration b) It tack constant vigilance to maintain an up-to- date problem list. b) The problem list in front of the chart alert the caregivers to the client needs and makes it easer to track the status of each problem. c) It is somewhat inefficient.

8. Cont’ The problem oriented medical record has 4 basic component : (POR) has four parts: 1- Database. Is an overview of patient information 2- problem list. The problem list is the first document encountered in the patient's char t. It serves as a guide to the current and important health problems of the patient. 3- plan of care. which specifies what is to be done with regard to each problem 4- progress note. which document the observations, assessments, nursing care plans, phy sician's orders, etc., of allhealth care personnel directly involved in the c are of the patient..

9. Cont’ The Integrated Health Record Format 3- The Integrated Health Record Format : Integrated health record format organizes all the paper forms in strict chronological order and mixes the forms created by different departments.

10. TYPES OF RECORDS 1. Patients clinical record 2. Individual staff records 3. Ward records Administrative records with educational value. 4.

11. PATIENTS CLINICAL RECORDS It is the knowledge of events in the patient illness, progress in his or her recovery and the type of care given by the hospital personnel. INDIVIDUAL STAFF RECORDS. A separate set of record is needed for staff, giving details of their sickness and absences, their carrier and development activities and a personnel note. WARD RECORDS. Reducting or increase in beds. Change in medical staff and non nursing personnel for the ward. ADMINISTRATIVE RECORDS WITH EDUCATIONAL VALUE. Treatments. Equipments losses and replacements. Personnel performance. Other administrative records.

12. Reporting DEFINITION Reports are oral or written exchanges of information shared between care givers of workers in a number of ways. A report summarises the service of the personnel and of the agency CRITERIA FOR A GOOD REPORT made promptly. clear, concise, and complete. If it is written all pertinent, identifying data are included-the date and time, the people concerned, the situation, the signature of the person making the report. It is clearly stated and well organized Important points are emphasized. In case of oral reports they are clearly expressed and presented in an interesting manner.

13. The purpose of reporting is: to communicate specific information to a person or group of people. ( an essential tool to communication ) To show the kind and amount of services rendered over a specific period. To illustrate progress in teaching goals. As an aid in studying health condition. As an aid in planning. To interpret the services to the public and to the other interested agencies.

14. REPORTS IN NURSING EDUCATION Factual data related to the students, staff, clinical facilities, physical facilities, administration and the curriculum Development made in the school programme since the last report. Proposal and plans for future development. Problems encountered Recommendations

15. TYPES OF REPORTS 1. 24 hours reports 2. Census report 3. Anecdotal report 4. Birth and death report 5. Incidental report

16. CLASIFICATION OF REPORTS BASED ON TYPES Oral reports Written reports

17. REPORTS USED IN HOSPITAL SETTING: CHANGE – OF – SHIFT REPORTS TRANSFER REPORTS INCIDENT REPORTS LEGAL REPORTS

18. Types of report : 1- Change – of- shift report : is report given to all the nurses next shift. It is purpose is to provide continuity of care for client.

19. Cont’ 2- Telephone Report : The nurse receiving a telephone report should document Ex: 6/6/03 10:35 AM Omar Ahmad, laboratory technician, reported by telephone that Mrs. Sara Mohammed hematocrit was 39/100ml ____ B.Irland RN.

20. Cont’ When giving telephone report to a physician telephone report include Ex: Dorothy Mendes admitted 12 noon; c/o burning upper right quadrant abdominal pain, BP 120/80, p 100, R 20, on admission. Demerol 100 mg IM on admission, At 3:15 pm BP 100/40,P 120, R 30. Pain unchanged. Color pale and diaphoretic. Reported by telephone to Dr. Burns at 2:10 pm ___ TS Jones RN.

21. Cont ’ 3- Telephone Order : While the physician gives the order write it down and repeated back to the physician. Ask the physician about any order that ambiguous, unusual, or contraindicated by the client’s condition. Transcript the order to the physician order sheet. The order must be countersigned by the physician within a time period described by agency policy.

22. Cont’ 3- Care plan conference : Is a meeting of a group of nurses to discuss possible solution to certain problem of the client. It is allow the nurses an opportunity to offer an opinion about possible solutions to the problem. 4- Nursing Round : procedure in which tow or more nurses visit selected client at each client bed side to : a) Obtain information that will help plan nursing care. b) provide the client the opportunity to discuss their care. C) Evaluate the nursing care the client has received.

23. ADVANTAGES AND DISADVANTAGES OF REPORTS ADVANTAGES Monitoring operations Controlling Guide decision Employee motivation Performance evaluation DISADVANTAGES It is time consuming. Expensive Reports can be biased Sometimes implementations of the recommendations of a report become unrealistic. Technical reports are not easily understandable

24. NURSES RESPONSIBILITY FOR RECORD KEEPING AND REPORTING Records and reports must be functional accurate, complete, current organized and confidential FACTS ACCURACY COMPLETENESS CURRENTNESS ORGANIZATION CONFIDENTIALITY 39.

25. COMMON PROBLEMS THAT OCCUR DURING REPORT WRITING.  CONTENT AND ORGANIZATION Problem - No section headings Problem - missing items related to the format Problem - lack of numbering 40. Common problems that occur during report writing.(Contnd..)  GRAMMAR, VOCABULARY, SENTENCE AND TONE.  OTHER PROBLEMS Incomplete sentences Confusing and unclear sentences. Miscommunication Too general Confidentiality. Missing information and facts. Wordiness.

26. Basic essential reports

27. Documenting Nursing activities 1- Admission Nursing Assessment :

29. Cont’ 2- Nursing care plans : 2 type Traditional Written for each client Standardized Developed to save documentation time

31. 3- Kardexes:

32. 4- Flow sheet :

36. 5- Progress note : Provide information about the progress a client is making toward achieving desired outcomes.

37. 6-Nursing Discharge / referral Summaries Completed when the client being discharged or transferred to another institution or to home where a visit by community health nurse. If the client transferred within a facility or from long term facility to a hospital, a report needs to accompany the client to ensure continuity of care in the new area. It is include some or all of the following : 1- Description of the client status. 2- Resolved health problem. 3- unresolved health problem and continued care needs

38. Cont’ 4- Treatment that are to be continued. 5- Current medication. 6- restriction that are relates to activities, diet, bath. 7- functional / self care abilities. 8- comfortable level. 9- Support network. 10- client education. 11- Discharge distention. 12- Referral services.

39. Thank you for your listening