Chapter Five

- Nursing records

*Nursing records

* identification Records

 Importance Records

 Points The task of keeping records

adjectives Featured for registration

Species Records

identification Records: 

1- is a tool It is used to arrange and record information and data, and it is one of the important management methods that... It is used in planning and evaluating work, developing plans, and following up on their implementation In education and research.

2- Records It is a tool Administrative: It is used to preserve and arrange information and prevent its repetition. It contributes to achieving goals Administration and the educational process.

3- They are models or administrative tools that are designed by the administration To collect important data to achieve the goal of the unit or facility.

NB :

-  considered as Records are the source of cumulative or important information that is used in care Patient, research and also making sound decisions.
-  The importance of records:
-  It is considered A record of the unit or department’s work and the nurse’s work in terms of type and quantity that can be referred to when necessary.

- It is one of the important management methods that are used In planning and evaluating businesses and developing operational plans, it is also used in research And education.

-  A tool for guidance When organizing educational programs and training courses for nurses and staff.
-  Do not repeat the tests that have been previously performed.
-  A tool for conducting Comparative research in the fields of the health Nursing.
-  Helps the patient Follow up on his condition in case the disease recurs.
* Helps in overcoming On the time problem.

-  A reliable document in legal problems To protect workers In the hospital and institutions Health.

-  A means of identifying the situation in society, common problems and diseases, and methods Her treatment.
-  Means of communication between the employee and superiors.
-  One of the methods used to evaluate the performance of the unit and workers.
-  Helps the doctor And nursing in Research and education Medical, diagnosis.
-  tracking Nursing care provided to the patient .

**Important points for record keeping:

-  It must be Records are accurate and current.
-  It must be Records are clear and concise.
-  You must provide Records important facts for evaluation and study.
-  He should  Save forms at all times.
-  He should  Keep confidential records and write them confidential in color red or printed.
-  You must save Records in a clean, dry place .

Distinctive features of registration:

-  Accuracy and clarity And honesty in registration.
-  All inclusive.
-  The data must be complete, correct and organized Sequentially and objectively.
-  Nothing with it Scraping or scratching, and in the case of scratching- It must be signed next to it, and the crossing out must be in handwriting One italic on the word and the signature next to it and the name is clear.
-  Accuracy of timing when reporting certain important information Or accidents or disasters that cannot be postponed.

•         The registration must be reviewed before signing it in terms of accuracy of information and clarity of handwriting.

The registration must be printed on paper Of good quality so it can be kept  with it And refer to it when necessary .

Types of records: There are types of Records

* Private records With the patient : It is composed

From the contents of a file The patient's condition is summarized from the time of admission to the hospital until the time of discharge or death- * Contains the patient file On the following records :

-  Evaluation newspaper Nursing care of the patient upon admission.
-  Marks sheet Vitality

-  newspaper Implementation of treatment.

-  Intake fluid balance sheet And the outside.
-  Insulin Method Sheet.
-  A newspaper for six preparations Processes.
-  Notes sheet Nurses.
-  Patient turning newspaper.

responsible Head of department.

Toward conservation Records.

Organizing and arranging new patient records, including:: Patients’ personal data, for example upon admission (age - name - diagnosis).

-  The form for monitoring vital signs the nurse.
-  Private papers With treatment.
-  Laboratory and x-ray forms And other records.
-  Records must be kept somewhere Amin, far from futility and loss.

Do not give records to others except in the case of transfer The patient, the study, or the treating physician.

-  Not separating Any paper from the patient's file for any reason
-  Not allowed To read the records of any patient’s relatives or any other person or persons except with written permission From the hospital director, the doctor responsible for the patient’s condition, or the head of the department- when Patient Discharge You must ensure that the record is organized, correct, and complete before sending it to the office Responsible for its preservation

- Giving instructions and training For new nurses on how to take correct complete notes or how to deal with... Papers.

- ought to Patient records and reports contain the patient’s progress from his admission until his discharge from the department The details are sufficient to make it easy to use to follow up on the patient's condition whenever necessary As well as carrying out scientific research.

The nurse's responsibility for records and reports.

 -  Because the nurse is legally responsible

If any records or reports in its possession are lost, it must be reported following the following.

- Keep it in a safe place and do not Allowing those other than those responsible for caring for and treating the patient to view it.
- Consider all data recorded in Reports and records are confidential.
- Give instructions Training for new nurses on how to record and take complete and correct notes.

- All information is kept in the patient’s record Patient treatment tickets and papers related to the research or operations performed on him during He stays in the hospital until he is handed over to the discharge office upon his discharge from the hospital

- Upon delivery Neoptia Or receive it with complete tracking accuracy Receiving patient treatment tickets

- Records or reports are yet to be received It is enforceable by officials according to the instructions specified by the hospital

- Be careful not to scratch, scratch or scratch Removing papers from records

The nursing role of records and reports :

- Taking into account the distinctive qualities of good recording and reporting

- Take into account the completeness of the file contents:

    -  Patient data

    -  Special forms for nursing registration

    -  Test and laboratory forms

    -  Using specialized departments

    - Treatment papers etc...

Keeping records in a safe place away from tampering and loss

Maintaining confidentiality and patient rights

Follow regulations and laws in submitting any information

Do not give records to others except in the case of transfer according to regulations and instructions

Explaining proper registration methods for new nurses

Make sure to complete the register before arriving at the exit office

The record contains everything that happened to a patient, developments, and discharge status.

**Types of records found in the office of the Chief Nursing Officer .

•         Record shifts at the level of all hospital departments for nurses.

•         Attendance Record.

•         Appointment records for nursing team members.

•         Calendar records.

•         Custody inventory records.

•         Employee performance evaluation records .

•         Time tables.