First Part

- Records and reports

The work of the nursing staff includes its various types, from the chief nurse to the inspectors- Supervisors and nurses write many reports and record health and nursing data.

The process of measuring performance and planning health nursing services depends on the accuracy of registration and the efficiency of records and reports. Therefore, attention must be paid to records and reports so that the information is correct, complete, accurate, recorded in a clear manner, and kept in a safe place so that it is not damaged or lost.

The importance of records and reports:

Records and reports have many important benefits that can be summarized as follows:

1-    A record of the unit’s work and the nurse’s work in terms of quantity and type so that it can be referred to when necessary.

2-    One of the means used to evaluate the performance of the unit and workers.

3-    Means of communication between the employee and the authorities.

4-    A tool for guidance when planning health and nursing services.

5-    A tool for guidance when organizing educational programs and training courses.

6-    A way to learn about the situation in society, common problems and diseases, and ways to treat them.

7-    A tool for conducting comparative research in the fields of health and nursing.

8-  A document that can be relied upon in legal problems to protect health workers and institutions .

Characteristics of good recording and reporting:

1-    Accuracy, clarity and honesty in recording.

2-    The data must be complete, correct, neatly arranged and objective.

3-    Accuracy of timing when reporting certain important information, incidents, or disasters that cannot be postponed, as reporting must occur immediately and at the specified time.

4-    The report must end with the signature of the informant or writer, the date, and sometimes also the time.

Reports:

A report is an oral or written message, the purpose of which is to convey information about a specific topic or incident for recording, reporting, or to take a specific action. Usually, reports are submitted from the subordinate to the superior on a regular basis and at specific times, with the exception of accidents and disasters, which are reported immediately upon their occurrence.

A good report is one that conveys information in a clear and precise manner, using simple sentences and without repetition- Use clear words that do not contain ambiguity or carry more than one meaning -And avoid using the building for the unknown -Choose the appropriate words that clarify the purpose -Ensure accuracy in writing, taking into account that there is sufficient time for drafting and review before signing, and a copy of the report must be kept for reference when necessary.

The report usually consists of the following parts:

1-    Name of the person or entity to whom the report is sent.

2-    Report Title- It must be brief, clear, and indicative of the subject of the report.

3-    A simplified summary of the topic.

4-    The introduction includes a quick presentation of the history of the topic, its development, and the special circumstances surrounding it in terms of time, place, and people  

5-    Body of the report- Or the main part of the report, which includes a complete presentation of the topic based on observations, interviews, and documents.

6-    The conclusion reached by the report writer and his personal opinion for treatment or solutions.

7-    Conclusion and recommendations.

8-    Signature and date.

There are many types of reports:

Including printed and standardized forms in all hospitals and units, such as statistical reports, reports attached to samples for laboratories, or a request to perform x-rays. ... etc.

There are also verbal reports, such as what the nurse informs her colleague in the next shift, such as the condition of a particular patient or a special treatment that is required to be performed. It is preferable to record this information in a written report as well for reference when necessary.

Methods of communication from the boss to the subordinate (from top to bottom) are in the form of administrative orders or instructions -Work guide -Bulletin board periodicals -Sometimes they are in the form of verbal instructions.

Most written communications that travel down from management to workers are issued in the form of administrative orders, work manuals, and bulletin board periodicals.

As for written data and information that come from workers to the top, they may include statistical data and information about the quantity and type of services, and written reports from subordinates to superiors may affect service planning and decision-making to solve problems, resulting in the achievement of goals. Good management gives instructions and directions to workers about the quality of data. The statistical information that must be included in the report for each nursing department or unit.

As for the reports prepared by supervisors or head nurses and inspectors, they are usually related to solving problems, what has been done and what should be done, as well as an evaluation of current production and quality of care, along with presenting suggestions to solve problems that are outside their control and authority. Written reports can be kept as documents and a source that can be referred to if they contain Provides correct, accurate and real information.

Reports related to nursing services management:

1 - Report of receipt and delivery of the shift:

Necessary as a means of communication to transfer and follow up information from one group of nurses to another group during the daily 24-hour work. These written reports provide the nurse with notes about the patients and what happened to them during the period preceding their work. The importance of this report is that a large number of nurses and members of the health team meet with The head nurse is required to provide the necessary data before writing the report, raise any questions, and reach clarifications and solutions to problems. The shift report makes the nurse aware of what happened.

2- Daily report:

This report is written by the hospital’s head nurse to the director to inform him about:

-       General condition of the hospital.

-       Statistics of patients who had changes or complications.

-       Cases of patients who have undergone changes or complications.

-       Patient cases that follow specific treatment or research.

-       Entry, exit, transfer and death cases.

-       critical cases .

-       The plan to be followed in the event of an emergency.

-       All cases with high fever, especially after birth.

-       Complaints from patients or service users.

-       There are many forms of this type of daily general report. 

3- Patient census report:

It is the official number of patients in the inpatient department or in hospital departments at a specific time, usually at midnight. The overnight nurse is responsible for writing this report, and its purpose is to know the number of patients in the inpatient department at any time, the bed occupancy rate, and the number of empty beds.

4 - Reports on work problems and the extent of progress in following the proposed solutions:

Writing reports on work problems and giving recommendations for solving them is an effective tool for obtaining facts and helping to direct discussion of a particular problem in meetings, as well as providing guidance for the follow-up system.

These reports also help other nurses, all members of the health team, and superiors know the real reasons behind these problems, so that they can confront similar problems that occur in the future and when evaluating progress in solving these problems and achieving the desired goals of work.

The following must be followed when writing reports on work problems:

1-    Definition of the problem and its size.

2-    Giving an accurate statement of the errors and what needs to be fixed.

3-    Analyze the reasons that led to these errors.

4-    Remember the roots of the problem as the report writer sees it.

5-    Proposed solutions to eliminate the causes of the problem, along with clarifying the people who will implement the solutions.

5- Reports on accidents and emergency situations:

The responsibilities of the nursing staff are to maintain the safety and well-being of patients and users of health services in hospitals and health units.

They are responsible for implementing and following up on the treatment and nursing plans for these patients, as well as for avoiding accidents and dangers that may occur in hospitals and health units. In order to provide insight and determine the duties of nursing staff members in the event of disasters or an emergency, they must be introduced to the hospital or unit system and how to inform their superiors. Work when internal disasters occur, as well as how to carry out their duties in response to them.

Therefore, one of the most important duties of the nursing services department in hospitals and health units is to follow a special system for reporting the occurrence of such errors and accidents as soon as they occur, and to alert and train nurses when they take up work on the necessity of reporting these errors and accidents to those responsible. One of the most effective methods of reporting is writing reports on accidents and emergencies. 

Reports of medication administration errors:

Such errors may occur from members of bodies that deal with issuing, preserving, or administering treatment to the patient, such as nursing staff, pharmacists, and technicians. This may indicate that they did not follow the necessary procedures of the hospital in giving and dispensing treatment. This may also be an indication that the doctor’s orders are necessary. It must be written accurately and clearly, and the pharmacy instructions written on the packaging must also be written accurately and clearly. 

Analysis of reports on accidents that occur to patients during their stay in the hospital or their visit to health units shows a lack of accuracy on the part of those responsible for caring for the patients. For example, negligence in not following the instructions issued by the head nurse regarding the operating room, which must be followed by the nursing staff and doctors, such as counting the technician’s towels before closing the wound. During the operation, the shortage of these pads is discovered before the opportunity is too late, so that the hospital bears this responsibility alongside the doctors and nursing staff.

Likewise, accidents may occur for workers due to failure to follow the appropriate method and methods at work. For example, when linens are not checked before putting them in their container to be sent to the laundry, the laundry workers may be exposed to injury from quickly leaving scalpels or sharp tools in them.

For each of these examples, it appears that nursing staff members have an important effective role in preventing accidents and mistakes that may result to patients and workers that may happen to the patient while he is in the hospital. Therefore, reports on the patient’s physical and mental condition must be recorded in the patient’s file and notified to the head nurse and the doctor. Whoever is responsible at the time, such as the appearance of bed sores or lice infestation, as well as an unwanted reaction to a treatment such as the occurrence of chills (shivers) when giving intravenous solutions or injections, must be recorded and reported to the specialist as incidents and recorded in writing in a report.         

The report of emergency incidents and treatment errors includes the following:

Patient's name and diagnosis.

Date of entry, frequency, or visit.

Time to notice and report the situation.

What was done to prevent the condition from occurring?

The circumstances of the situation, its dimensions, and the unusual factors that affected the environment at the time the situation occurred.

Steps taken to correct the situation and remedy the error.

Date, signature of individuals writing the report.

Suggestions from the head nurse to prevent such an error from occurring and are sent to the director of the hospital or health unit  .

6- Reports on patient complaints:

The patient's complaint must be reported immediately to the head nurse, and it is important for both the nursing team leader and its members to become aware of the patients' complaint and their relatives from the beginning of the complaint so that it does not escalate and so that it facilitates the study and analysis of nursing plans to find appropriate solutions at the right time.

It is possible that complaints submitted by patients and their relatives regarding the quality of services provided constitute a kind of effective participation in directing these services in the interest of patients, workers, and the institution alike, by involving the patient in implementing the plan drawn up to care for him. Therefore, nursing staff members must consider the complaint objectively. The patient is assisted in accepting the necessary adaptation while he stays in the hospital, implementing his treatment, and accepting health instructions.

Such a report includes the following:

·      The content of the complaint and its justifications as stated by the patient.

·      Actions taken to resolve the complaint.

·      The result .

·      Date and signature .

7- Administrative reports:

Sometimes the executive authority and directors of hospitals and health units request writing and submitting monthly, quarterly, or annual reports from each department or unit of the institution or hospital. The Nursing Services Department may request written and periodic reports from the heads of nurses and nursing units in the hospital. Likewise, nursing inspectors often request monthly reports from Head nurses of health units.

Such a report includes the following:

·      A brief account of the unit’s activities, the type of nursing staff, the number of working hours and shifts, and statistics on births, admissions, discharges, deaths, and home visits.

·      Current capabilities of machines, tools and maintenance status.

·      Problems affecting nursing care in terms of manpower, environment, machines and tools.

A narration of the reasons for bringing about a change in the work pattern in terms of labor or resources and the result of this change, giving evidence and indicators that prove these changes and their results.

These reports must be taken seriously by superiors and their results must be followed up until the changes required to raise the level of services in health units are made. If they are not taken seriously, these reports are considered a waste of time and energy and become unproductive. …

Records:

The Definition :

Records are an administrative tool used to preserve and arrange information and prevent its repetition. They contribute to achieving the goals of administration, the educational process, and conducting scientific research.

The following are the different types of records used in hospitals and nursing units:

1- Patient file:

It is the document that indicates the quality of health care given to patients or beneficiaries of health services. It includes information pertaining to the patient since his admission to the hospital or his first visit to the health unit, as well as his laboratory tests, observations, details of therapeutic procedures, as well as the patient’s reaction to the treatment and services provided to him.

* It also contains records of consultations for treatment and surgeries.

* It also has separate papers to record treatment and medications.

They are not only records to collect information about the patient, but they are also considered a legal document used when necessary in judicial cases, and therefore the data contained in the patient’s file has a privacy character.

There are many efforts being made to raise the level of efficiency of using records as an administrative tool at all levels of health services.

The patient's record (file) is used for the following purposes:

·      Helping to reach diagnosis and treatment.

·      Recording the services provided to the patient.

·      Contributing to education and conducting research after the patient’s approval.

·      It is used as an important legal document in cases brought before the judiciary.

·      It is used in quantitative and qualitative analysis when evaluating services 

The nurse's responsibility regarding patient files:

Organizing and arranging the records of new patients and patients, provided that these files include the following:

·      Complete personal data for patients and visitors.

·      Forms for vital signs and nurse notes.

·      Laboratory forms, x-rays, and other records for specialized departments

·      Treatment papers.

Responsibility of the unit head nurse towards keeping patient records:

·      Records must be kept in a safe place away from tampering and loss.

·      Do not give records to others unless the patient is referred for study or to the treating physician.

·      Do not delete any paper from the patient’s or patient’s file for any reason.

·      No one, including relatives, friends or families of patients, is allowed to read the records except with written permission from the director of the hospital or unit.

·      Providing guidance and training to new nurses on how to take complete and correct notes.

·      When the patient is discharged, you must ensure that the record is organized, correct, and complete before sending it to the office responsible for its preservation.

·       Patient records and reports must contain the patient’s progress from his admission until his exit from the unit, and the details must be sufficient so that it is easy to use in following up on the patient’s condition whenever necessary, as well as when conducting scientific research  .

2- Records for recording the nurse’s notes:

This includes recording accurate observations about the patients’ condition and the nursing care given to them. It also includes special information related to medications, treatment, food, and health instructions, as well as recording notes about the patient’s physical and psychological condition, the patient’s reaction to treatment, the extent of his adaptation to the disease, and any change that may occur in his condition.

The purpose of this record:

·       There should be a unified record agreed upon by all employees in one hospital for writing notes by nurses to facilitate the transfer of responsibility from one nurse to another during different working hours.

·       Facilitating the rapid review of the patient's condition and the performance of nursing care.

·       Emphasize the importance of recording the nurse's notes.

3- Records of distribution of duties to members of the nursing team:

·       It includes the names of the nursing staff members working in the unit and the names of the patients assigned to their care, as well as the special duties assigned to each of them. There must be a unified form that is filled out daily by the head of the unit’s nursing staff, and this record must be placed in a clear and known place for everyone.

The record of assignment distribution includes the following:

·       Name of the nurse in charge.

·       Patient name .

·       Diagnosis.

·       Needed nursing care or special treatment and research.

·       The type of duties the nurse is responsible for, such as assisting the doctor in examining or giving treatment to patients.

·       As well as special duties such as preparing to give injections or preparing the dressing cart for wounds.

The purpose of this record:

·       Informing the nursing team members working in nursing units in hospitals and health units in writing about their daily responsibilities.

·       Determine nursing responsibility for each patient.

·       A basis for evaluating nursing care given to patients.

4- Shift tables:-

·       It is a record that is prepared weekly and daily and specifies the plan drawn up to cover the nursing and health unit with nursing staff over a 24-hour period and includes the following:

·       Names of the unit's nursing staff.

·       The different levels of nursing staff members are in groups over the course of a week with a detailed 24-hour schedule on the number of shifts.

·       Name of the head nurse in each shift.

·       Rest days, sick leave, excuses and absences.

·       Meeting times, rest hours, and lunch.

The purpose of this record:

·       It shows the units' coverage of the nursing workforce and the extent of its adequacy.

·       The presence and absence of nursing staff in the unit is recorded daily.

·       It provides information about all nursing services in relation to the numbers and levels of the workforce.

·       It also shows the number of working hours for each nurse.

5- Custody inventory records:

·       Labeled records for all appliances, furniture, tools, and machines, specifying the quantity, specifications, and condition of each.

The purpose of this record:

·       Providing the head nurse with information about tools that are missing, broken, or need to be repaired

·       Return the surplus to its appropriate place, as well as the borrowed tools, before counting or inventorying the item.

6- Employee performance evaluation records:

These are records used to evaluate the performance of employees annually or every six months.

The Purpose :

·       An objective basis on which employees are promoted and given rewards and incentives.

·       An incentive for employees' professional advancement.

·       It explains the reasons for poor performance and gives recommendations for good work.

7- Time tables:

·            For routine and non-routine work.

The purpose :

·       It shows the time when activities occur, which are daily, weekly and monthly.

·       Daily schedules show the times when the unit's routine activities occur.

Monthly time sheets such as when monthly reports and orders are submitted.

1.     Supervision notebook.

Patient entry and exit record book.

Department delivery and receipt book.

Nursing records book.

Emergency vehicle delivery and delivery book.

Delivery and delivery book for sterilization.

Patient treatment notebook.

Medical report book.

Medication dispensing book from the pharmacy.

X-ray order book.

Notebook of unexpected events.

Furniture notebook.

Maintenance book.

Malfunction reporting book.

Daily cash register.118