Part One

- Records and Reports

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 surgical operations.

There are also 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.

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.

Responsibility of nursing personnel 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 observations of nursing staff.

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 nursing personnel 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 nursing personnel’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 nursing personnel to facilitate the transfer of responsibility between nursing personnel during different working hours.

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

·   Emphasize the importance of recording nurses’ 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 duties distribution record includes the following:

·   Name of the responsible nursing personnel.

·   Patient name .

·   Diagnosis.

·   Needed nursing care or special treatment and research.

·   The type of duties that nursing staff members are 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 a dressing cart for wounds.

The purpose of this record:

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

·   Determine nursing responsibility for each patient.

·   A basis for evaluating the 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.

·   The 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 explains the coverage of the units with the nursing workforce and the extent of its adequacy.

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

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

·   It also shows the number of working hours for all nursing personnel

- Custody inventory records:

·   Labeled records for all devices, furniture, tools and machines, identifying 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 excess to its appropriate place, as well as the borrowed tools, before counting or inventorying the item.

Employee performance evaluation records:

·     These are records used to evaluate employees’ performance annually or every six months.

·     the purpose :

·   An objective basis on the basis of 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 to submit monthly reports and orders.

Types of records

·  Delivery and pick-up

·   Department records book

·   The custody book

·   A notebook of unexpected events

·   Maintenance book

·   Malfunction book

·   Entry and exit book

·   Work and tasks distribution book

·   Emergency vehicle delivery and delivery book.

·   Delivery and receipt book for sterilization.

·   Patient treatment notebook.

·   Medical report book.

·   Medication dispensing book from the pharmacy.

·   Radiology order book.

·   Furniture notebook.

·   Daily cash register.118