reporting in nursing

REPORTING IN NURSING...

A N I L K U M A R B R , L E C T U R E RM E D I C A L - S U R G I C A L N U R S I N G * * * * * * *

WITH BLESSING OF ಏಕದಃತ

REPORTING....

• REPORTS are oral or written exchange of information shared between care givers ( Health care team) in a number of ways.

INTRODUCTION.....

• Communication is corner stone in the nursing professional and essential part of the nursing care.• Nurses communicate information about client’s/ patient’s so that all health care team members can make appropriate decision making about client’s care.

TYPES OF REPORTING IN NURSING......• ORAL REPORTS• WRITTEN REPORTS

ORAL REPORTS....

• Oral reports are given when the information is for immediate use and not for permanency.

WRITTEN REPORTS....

• Written reports are to be written when the information to be used by several personel which is more or less of permanent.

TYPES OF REPORTS IN NURSING......• Commonly used reporting in nursing.......1) Change-of-shift reports2) Transfer reports3) Incident reports and4) Telephone reports

CHANGE-OF-SHIFT REPORTS...(CSR)• This type of reporting most commonly using.• At the end of each shift nurses report information about their assigned client’s to the nurses working on the next shift.• The rport provides continuity of nursing care among nurses who are caring for a client.

EXAMPLE FOR CSR...

• If first shift nurse finds a certain pain relief measure effective for a client, it is essential that the information be related to the next nurse carring for the client so that pain control intervention can be continued.

GUIDELINES FOR GOOD CSR....• Provide only essential background data on patient(e.g name,age,gender,M.diagnosis, and history)• Describe objective measurements about patient condition an response of health problem• Evaluate results of nursing or medical care measures.• Be clear on priorities to which oncoming staff must attend.

CONTINUE....

• Don’t review all routine care and procedure or tasks• Don’t review all biographical data already available in written form•Don’t use critical comments o patient behavior

TRANSFER REPORTS....

• Patient’s are often Transfer from one unit to another to receive different levels of care and treatment.• E.g client’s transfer from an ICU or critical care units to general nursing units when the client stable or no longer requires such intense monitoring.

WHEN A GIVING A TRANSFER REPORT ,THE FOLLOWING INFORMATION SHOULD BE GIVEN....

• Patient name,age,primary Physician and Medical diagnosis• Brief summary of progress up to the time of transfer• Patient health status (physical & psychological)• Allergies (regarding drugs and medications)• Current treatment status (IV fluids,blood transmission any other)• Current nursing diagnosis or problem and care plan

CONTINUE.......

• Patient current vital sings and heamodynamic status ( TPR,BP HR,RR,SpO2,ECG etc)• Any critical assessment or procedure performed before going to transfer a client• Need for any special equipment ( Cardiac monitoring,sucton equipment etc)

INCIDENT OR OCCURRENCE REPORTS....• An incident is any event that is not consistent with the routine operation of health care unit.• incidents are commonly occur when patient under care within hospital settings.• Incident reports are in major part of a unit quality improvement program

TYPE OF INCIDENTS

• Falling from bed or in toilet• Neddele stick injuries• Burns (hot Application or from other sources)• Drugs or medications administration errors• Mis identification of patient• Accidental omission of ordered therapies

GUIDELINES TO REPORT INCIDENT • Describe in concise what exactly happens especially in objective

terms• Enumerate incident unit, time etc• Explain patient condition before and after the incident (physical

& psychological)• Describe any treatment is given after incident• Record patient vital sings after incident

CONTINUE...

• No nurse should blamed in an incident reports• As possible soon submit a repot to the authority.

TELEPHONE REPORTS....

• Nurse’s inform Physician or other health care team members regarding changes in patient condition during caring and communicate information to nurses on other units about client’s Transfer.

CONTINUE...

• Telephone reports also can be utilizes a laboratory staff or other radiological staff to providing immediate results about patient.• Telephone reports must contain clear,accurate,and concise.

GUIDELINES FOR TELEPHONE REPORTS.....• It should be clearly patient name ,room, unit no,IP number and diagnosis.• Repeat the reports any communication error occur•Use clarification questions to avoid misunderstanding.

JAI HIND,... JAI KARNATAKA...