Chapter Five
- Nursing reports
Objectives :
1- Definition of what is meant by reports.
2-Discuss the importance of the report.
3-Identify the different types of report.
4- Mention the specifications of a good report.
*the introduction:
The work of the nursing staff, in its various types, includes writing many reports and recording health and nursing data. The process of measuring performance and planning nursing services depends on the accuracy and efficiency of the reports. Therefore, the importance of nursing reports must be understood so that the information is correct, complete, accurate, and written in a clear manner, so that nursing staff members understand the extent of its importance and providing nursing care. At a high level.
*Definition of reports :
1- Exchanging information from one person to another or from one person to others.
2- Rapid delivery of information to ensure the provision of up-to-date information that is important to all members of the health team, which helps them make appropriate decisions for nursing care.
3- It is one of the means of communication and its purpose is to deliver real and realistic information to the right person at the right time.
4- Reports are verbal, written and also computer-mediated communication that aims to convey information to others.
*Nursing reports are:
A method of communicating specialized or specific information to a person or group of nurses, verbally and in writing, in order to identify significant changes in a patient's condition and communicate these findings to the relevant health team members. Reports are also not only a collection of information about the patient, but they are a document used when necessary.
*The importance of reports:
1- A complete report gives a sense of security resulting from knowing all the factors related to the situation.
2- It is considered one of the methods used or being used to evaluate nursing staff.
3- It is considered one of the means of communication and its purpose is to deliver real and factual information.
4- It is considered a document that can be relied upon in legal problems or a document used when necessary.
Types of reports:
* There are two types of reports:
*External reports:
They are exchanged between the nursing administration and other departments, such as radiology or analysis, or they are reports that are exchanged between two different departments, such as the report that is exchanged between members of the nursing staff and the admission office (statistical report).
*Internal reports:
These are reports exchanged between different members of the nursing administration, or they are reports exchanged within a single department between its members, or between members of a single department that are exchanged between members of the nursing staff, such as (department conditions report - hospital conditions report - accident report).
*Characteristics of a good report:
1- Reports, whether verbal or written, must contain current, accurate and concise information.
2- Legitimate communication channels must be followed when exchanging reports.
3- I must pay attention to accuracy and clarity while writing reports.
4- The data must be complete, correct, sequential and objective.
5- Accuracy of timing must be taken into account when reporting certain important information or incidents that cannot be postponed, as reporting must occur immediately.
6- Reports must be written in ink.
7- There are no shortcuts.
8- There are no scientific terms in it.
9- There is no abrasion.
10- A date must be specified.
11- The contents of reports must be correct and reflective
Indeed, it contains all the data in a concise manner.
12- It must be signed by the person responsible fo writing reports and writing the date of its editing .
Department status report
1- Definition of what is meant by a department status report.
2- Determine the purpose of using the adverbs of the section.
3- Explain the importance of the department’s conditions report.
4- Mention the qualities that must be present in the department’s report.
5- Description of the content of the department's condition report.
6- Use the department status report in different situations.
7- Description of the procedures that must be followed when writing a department condition report.
Department status report
*Introduction: This type of report is :
The oldest report in nursing management, and its longevity is considered due to its importance in moving work goals forward, but despite the introduction of many changes in the way it is written, it is still necessary as a means of communication to transfer and follow up information from one group of people to another group during daily work, 24 hours a day. This type of report provides the department's head nurses with observations about patients and what happened to them during the period prior to their work. Reporting on the department’s conditions keeps the department head informed of what is happening. Hence, the nursing team that will be given will be constructive, continuous, and based on a specific and thoughtful goal, and this report has educational potential at the time of changing or exchanging shifts.
*Definition :It is a verbal and written report that is exchanged by the head nurse of the department or her caretaker at the beginning of the next shift or at the end of one work shift and the beginning of another. This is to inform the nursing staff members of the upcoming shift of changes in patients’ condition, different treatment regimens, and nursing needs.
*The importance of reporting the department’s conditions:
1- A complete report gives a sense of security resulting from knowing all the factors related to the situation.
2- It is considered one of the methods used or being used to evaluate the nursing staff in the department.
3- When the condition report provides complete and consistent data, this leads to better service for the patient.
*The purpose of the department’s conditions report:
1- Transferring information or data based on actual, documented facts.
2- Securing or ensuring continuity of nursing care for patients.
3- Improving the nursing care provided to patients.
4- Preparing workers to carry out their daily work according to the patient’s condition.
*Qualities that must be present in the department’s status report:
¯ It must be written in ink.
¯ It has no shortcuts.
¯ There is no abrasion.
¯ It contains no scientific terms.
¯ It must be accurate.
¯ Must be organized.
¯ It must be written in clear handwriting and in understandable language.
¯ To be comprehensive. To be brief.
¯ The date and time must be specified.
¯ It must be signed by the person responsible for writing the report.
*Content of the department’s condition report:
*The report consists of three parts:
1- The department head must begin with the introduction and include :
⬅️ Total number of patients in the department.
⬅️ Number of admissions.
⬅️ Number of exits.
⬅️ Number of conversion cases.
⬅️ Number of deaths.
⬅️ Number of critical cases.
⬅️ Number of cases of preparation for operations.
⬅️ Number of recent operations cases.
2- Report content: via
Information is collected about the condition of each patient, and a brief report is written in front of each patient, such as [high temperature 39 degrees] and remembers what was done in case of high temperature, such as applying ice water compresses and informing the doctor. The temperature was measured after an hour and it was 38.5 degrees, and the temperature is taken into account. Every two hours.
3- Critical cases and operations report:
A brief report must be written about critically ill patients and operations. It includes:
⬅️ Degree of awareness.
⬅️ Nursing notes.
⬅️ Vital Signs.
⬅️ Patient complaint.
⬅️ Intravenous fluids required.
⬅️ Required tests.
⬅️ Incoming and outgoing fluids.
⬅️ The condition of the wound, if any, and its replacement.
⬅️ The tuber, if any.
⬅️ Rail, if any.
⬅️ Catheter, if present.
⬅️ Bowel movement after operations.
*Remember each patient individually by describing his condition as it is. If there is no change in his condition, write [his condition is stable]. If changes occur in the patient’s condition, you must mention the changes and what was done in a brief form.
Hospital conditions report
· Defining what is meant by a hospital conditions report.
· Determine the purpose of using the hospital conditions report.
· Mention the qualities that must be present in the hospital conditions report.
· Description of the components of the hospital conditions report.
· Description of the procedures that must be followed when writing a hospital conditions report.
· Explaining the instructions for reporting hospital conditions in its form.
Hospital conditions report
*The definition of the hospital conditions report is:
1- A report is exchanged from the unit to the head nurse's office. It is a summary of the cases and treatment plans for a specific group of patients and is written by the department head or her caretaker at the end of the shift.
2- It is the exchange of information between the hospital's head nurse and her caretaker during the evening or evening shifts.
*Usage objectives:
1- Exchanging information about the presentation of critical cases in the hospital.
2- It can be used to demonstrate the performance of nursing care for the patient.
*Characteristics that must be present in a hospital condition report :
⬅️ Hospital conditions must be written in ink.
⬅️ It has no shortcuts.
⬅️ It has no abrasion.
⬅️ It contains no scientific terms.
⬅️ Specific to the section and type of section.
⬅️ Specified by date.
⬅️ Brief.
⬅️ precise.
⬅️ Organizer.
⬅️ It has no spelling errors.
⬅️ Signed by the person responsible for writing it.
*Components or content of the hospital conditions report :
This report is written in the special form by going to the different departments in the hospital at the end of the shift and asking about the number of patients in the department.
⬅️ Section type.
⬅️ Number of patients in each department.
⬅️ Total number of patients in the whole hospital at the time of delivery 2am, 8pm, 8am.
*Type of patients included in the report:
⬅️ All patients before operations.
⬅️ All patients after operations.
⬅️ All admissions.
⬅️ All cases exit.
⬅️ All cases of death.
⬅️ All transfer cases.
⬅️ All critically ill patients.
⬅️ All patients with changes in vital parameters.
⬅️ All patients who require careful medical intervention.
⬅️ All emergency cases (diabetic coma - bleeding - convulsions).
⬅️ Depression cases.
⬅️ Burn cases over 75% .
⬅️ Cases at risk of suicide attempts.
⬅️ The report does not include those with stable conditions.
* The patient's name and a simple summary of his condition are written in front of the shift in which the conditions are collected, and this report is exchanged from the head nurse of the hospital, who is responsible for supervising the hospital in the evening shift, and also from the one responsible for supervising the evening shift, who is responsible for supervising the hospital in the night shift. It is then exchanged between the person in charge on the evening shift and the head nurse at the hospital in the morning.
Incident report
1-Definition of what is meant by an accident report.
2- Determine the purpose of using the incident report.
3- Enumerate the types of accidents that can occur.
4- Mention the characteristics that must be present in the accident report.
5- Describe the procedures that must be followed during the incident.
6- Explanation of the instructions for the accident report form.
Incident report
*the introduction:
It is the responsibility of the nursing staff to maintain the safety and well-being of patients and to implement and follow up on treatment and nursing plans. As well as avoiding accidents and errors that may occur in the hospital. In order to determine the duties of nursing staff in the event of accidents, they must be taught how to report the accident during or immediately after it occurs, as well as how to carry out their duties regarding it or towards it.
To ensure a safe environment within the hospital, the nursing staff must be careful to perform their duties in a way that reduces and prevents errors and the occurrence of accidents. This is to protect patients and protect themselves and those working with them. The nursing staff must follow the proper methods for reporting incidents and dangers as soon as they occur, by writing an accident report. Writing such a report ensures the security, safety and comfort of patients, the nursing staff and those working with them, and protection from their exposure to legal accountability .
*The definition of an accident report is:
An accurate and comprehensive report on unexpected incidents that could affect the patient, his family members, or members of the nursing staff.
In addition, the incident report is considered an internal system for the health organization. It is necessary for internal use in the Quality Assurance Program and is made confidential to the Committee through Quality Assurance Committee meetings.
*Purpose of use:
1- An inventory of incidents that occur in the nursing unit.
2- To ensure a safe and secure atmosphere for patients, their families, and individuals working in the hospital.
3- To determine how to prevent dangerous incidents that could affect any individual within the hospital.
4- To investigate errors that occur within the nursing unit and find out their causes so that they do not occur.
5- It is used to document any abnormal event in the hospital system and patient care.
6- This report is used as a reference until any special or specific incident occurs regarding the quality of nursing care given in the unit, in which the nursing staff members are accused of negligence and are subject to legal accountability.
* Types of accidents that can occur:
- The patient falls from the chair, in the bathroom, or from the bed.
- Treatment error.
- Error in using machines.
- Error in nursing procedures.
- Error related to patient behavior.
- An error related to the behavior of (visitors).
- Error related to theft.
- Diagnostic error.
- Error related to missing items.
- An error related to the transfusion of blood or solutions.
- A fire occurs.
- An injury occurs.
*Qualities that must be present in an accident report :
1- An accident report must be written in ink.
2- It has no shortcuts.
3- It contains no scientific terms.
4- It has no abrasion.
5- Specifies the date of the incident.
6- Specifies the time the incident occurred.
7- Specified by the type of incident.
8- Specifies the location of the incident.
9- To be precise.
10- Brief.
11- Write a description or comment from the department head.
12- Signed by the person who witnessed the incident.
Incident report form
the hospital :
the date :
the time :
Section :
· Please tick ( √ ) in front of the type of incident
1- Patient falls ( )
2- Treatment error ( )
3- Error related to the use of machines ( )
4- Error related to nursing procedures ( )
5- Error related to patient behavior ( )
6- An error related to visitor behavior
7- Error related to theft
8- Error related to missing items ( )
9- Another mention
Summary or description of the incident:
The doctor has been informed Yes ( ) No ( )
The patient was examined Yes ( ) No ( )
The direct manager has been informed Yes ( ) No ( )
Damage resulting from the accident:
1- There are no damages ( ) 2- There are serious damages ( )
2- There are damages related to the accident ( ) 4- Death occurred ( )
Signature of the department head
Signature of the person in front of whom the incident occurred
Reports related to nursing services management.
· Shift receipt and delivery report
· Daily Report
· Patient statistics report
· Reports on work problems and progress in following the proposed solutions
· Reports on accidents, emergency situations, and reports of treatment errors
· Reports of patient complaints
· Administrative reports
These reports must be taken seriously by superiors and their results must be followed up until the required changes are made to raise the level of services in health service delivery units. If they are not taken seriously, these reports are considered a waste of time and energy and become unproductive.