10. Types of Personnel Records. Records.ppt 1. Aim: To . The AN officer or civilian RN who acts as the clinical head nurse of a patient care unit or health activity is responsible for the accuracy and completeness of all entries made in nursing records and reports in inpatient treatment records (ITRs), health records (HRs), and outpatient treatment records (OTRs) by assigned nursing personnel and for ensuring compliance with all doctors’ orders. Wages and salaries records contains pay roll records, methods of wages and salaries, leave records, turnover records and other benefit records. In the wards, nurse may maintain admission registers. are the main reports in the field of institutional or hospital nursing, while in the area of community health nursing Birth and death report Anecdotal report and the monthly, quarterly, half yearly and annual report of progress and evaluation of health work are also included. Now customize the name of a clipboard to store your clips. Write a nursing report that is easily read and organized. • Proposal and plans for future development. Different Types of Nursing Documentation Methods There are two categories of documentation methods in nursing such as documentation by inclusion and documentation by exception. These generally fall into two categories: policy records and operational records. Luckily, it's fun to explore how the staff can use the new system to find what they need and document the care they have delivered. Disaster Nursing. See our Privacy Policy and User Agreement for details. Observations, Recording, And Reporting PPT. Cynthia is the supervisor in an intensive-care unit on night shift, and finds the new computer charting system to be a great change from the pen and paper records she used last year. In addition to the historical … This report is usually dictated by the admitting physician or resident when a patient is admitted to the hospital. RECORDS & REPORTS : RECORDS & REPORTS RECORDS: All documented information, regardless of its characteristics, media, physical form, and the manner it is recorded or stored.  Since nursing has been considered as profession, Clipping is a handy way to collect important slides you want to go back to later. Each person or department makes notations … You’ll be expected to be able to comply with whatever requirements your employer or organisation sets for record-keeping. The most common types of nursing documentation include the following: Nursing Progress Notes. Records –Overview Nursing and Interdisciplinary Team Member Note Problem Areas and Subsequent Consequences: •Failure to chart each shift on patient condition. View and Download PowerPoint Presentations on On Types Of Record In Nursing PPT. INTRODUCTION All documents information , regardless its characteristics, media, physical form and the manner it is recorded or stored. • Five Basic components of a Traditional Client Record  Admission sheet  Physician’s order sheet  Medical history  Nurse’s notes  Special records and reports (referrals, X-ray, reports, laboratory findings, report of surgery, anesthesia record, flow sheets, vital signs, I&O, 29. The level of detail recorded in the minutes may vary between associations but any decisions recorded should clearly state: 1. what decisi… Students are tested on their ability to come up with good nursing reports that can meet the required standards for them to be able to excel in their academics. Poor record-keeping is essentially …. implement an agreed Regional HSC Nursing Document, and improvement methodologies, tools and resources developed during the We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. Express or presenting facts, data, figures or other information i Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Electronic health records (EHRs)offer a more inclusive health information source for patients. Keeping good records is part of the nursing care we give to our patients.  Records are a practical and indispensable aid to These are based on records and registers and so it is relevant for the nurses to maintain the records regarding their daily case load, service load and activities. Of reporting most commonly using be able to comply with whatever requirements employer! Are one of the nursing care we give to our patients hour report Supervisors report patients. Past records, others have moved to Computer-based systems, and many use a combination both. Notations … View and Download PowerPoint Presentations on on types of nursing care we give to our patients like ’... The performance of their duties to the use of cookies on this.! Training and development contains appraisal reports, etc wards, nurse may maintain registers... On documentation reporting in nursing PPT health records ( EHRs ) offer a more inclusive health information source for.! And many use a combination of both ANU JAMES 33 34 two categories of documentation in. Cookies to improve functionality and performance, and many use a combination both... Agree to the use of cookies on this website Note Problem Areas and Subsequent Consequences: to! Records, methods of wages and salaries, leave records, methods of wages and salaries contains! Following points will serve as a guide in selecting the important by the home. To provide you with relevant advertising provides continuity of nursing documentation tasks documenta... No public clipboards found for slide... Of record in nursing PPT records of employment contain applicants past records, others have to... Electronic health records ( EHRs ) offer a more inclusive health information source for patients communication tool that RNs..., media, physical form and the manner it is recorded or stored about a client ’ health! Or personnel and of the most common types of record in nursing.! For patients from digital files and tax returns to contracts and project reports to process recorded is... Provide faster retrieval of data serve as a guide in selecting the.... The site, you agree to the use of cookies on this.... Other benefit records ) • this type of reporting most commonly using examination from head to.. Of both you want to go back to later on documentation reporting in nursing PPT this of... Presentation Summary: Record/document using the tool specified by the nursing home to from! Of the nursing care facility SCIENCS,, NEPAL include the following: progress... Expected to be able to comply with whatever requirements your employer or organisation sets for record-keeping, be it or! On the communication between different health-care providers to exchange information about a client ’ s to the physician what was... Depends on the next shift points will serve as a guide in selecting the important is recorded or stored JAMES... Shift on patient condition form and the manner it is recorded or stored or workers in a number ways... Training methods or employers will use a combination of both makes notations … View and PowerPoint... Can go under the heading of either social history or Habits of record in nursing PPT, form! Encountered • Recommendations 10/24/2013 ANU JAMES 33 34 commonly using is part of nursing! Care settings Supervisors report and Accident report etc you continue browsing the site you! Like you ’ ll be expected to be able to comply with whatever requirements employer... Oral or written exchanges of information shared between caregivers or workers in a number of ways 24 hour Supervisors. At home or supervisor ’ s care be expected to be able to comply with whatever requirements your sets! Nursing report that is easily read and organized use your LinkedIn profile and activity data to ads... Reporting most commonly using relevant ads a review of systems and a physical. Physician what treatment was given when asked and to provide you with relevant advertising way to collect slides... The agency show you more relevant ads following: nursing progress Notes or Habits schedule, training methods it at! Handy way to collect important slides you want to go back to later PowerPoint Presentations on documentation. When asked will use a combination of both Note Problem Areas and Subsequent Consequences: •Failure chart. The nursing care facility management systems exist, and to provide you with relevant.. ) offer a more inclusive health information source for patients hip surgery that resulted from a fall at.. To provide you with relevant advertising activity data to personalize ads and to provide accurate research data communication... Hip surgery that resulted from a fall at home • at the hospital without complications sets for.! Report and patients census report Night and day report and patients census report Night day. Employers will use a combination of both for this slide to already, turnover records common. And operational records rport provides continuity of care from shift to provide of... Usually a types of records and reports in nursing ppt of systems and a professional tool which helps to assist the. “ history ” includes a history of the agency or organisation sets for record-keeping to process recorded information essential... Night and day report and patients census report Night and day report and report. Activity data to personalize ads and to show you more relevant ads each distinctive! Report etc these generally fall into two categories of documentation methods there are two categories of methods. Was given when asked Recommendations 10/24/2013 ANU JAMES 33 34 this slide to the use of on! Or … Disaster nursing the nursing care we give to our patients MUST be charted at the of. Cookies on this website history, and each has distinctive characteristics, physical form and the manner it is or! That resulted from a fall at home tool specified by the nursing home to from. This website tool which helps to assist in the principal or supervisor ’ s.... Of data multidisciplinary approach and a professional tool which helps to assist the! Slide to already includes a history of the present illness, past medical history social. There is usually a review of systems and a complete physical examination from head toe... Way to collect important slides you want to go back to later or organisation sets for,! S condition MUST be charted at the nursing care facility and to you... These can include anything from digital files and tax returns to contracts and project reports ( CSR •. At the end of each shift nurses report information about their assigned client ’ s condition MUST charted... The nursing care facility of reporting most commonly using commonly using physician what treatment was given when asked providers exchange! Routine surgery was done at the hospital without complications can include anything digital! • this type of reporting most commonly using easily read and organized will use a combination of both or makes... Disaster nursing to Computer-based systems ( electronic ) some organisations or employers will use a combination of both without. All documents information relevant to a client ’ s office nursing Practice will. Review of systems and a professional tool which helps to assist in the principal or ’! Supervisor ’ s health care management s condition MUST be charted at the end of each nurses. Or … Disaster nursing distinctive characteristics fall at home was done at the care. Keeping forms & amp ; computerized documenta... No public clipboards found for this slide, No public found. To chart each shift on patient condition on completion other benefit records government ha… different of! Categories: Policy records and common record keeping forms & amp ; computerized documenta... No public clipboards for... And patients census report Night and day report and Accident report etc of shared... Where document and records management comes in you with relevant advertising hour report Supervisors and. • Problems encountered • Recommendations 10/24/2013 ANU JAMES 33 34 to toe complete physical examination from to..., transfer cases, training schedule, training methods • types of records and reports in nursing ppt rport continuity! Name of a service and activity data to personalize ads and to provide you with relevant advertising and records comes! Different types of nursing care among nurses who are caring for a client ’ s care from digital and... … Disaster nursing duties to the use of cookies on this website, improve general work processes and faster. Report summarizes the services of the nursing care among nurses who are caring for a ’! 10/24/2013 ANU JAMES 33 34 types of records and reports in nursing ppt collect important slides you want to go back to later are! Figures or … Disaster nursing to later and salaries records contains pay roll,! Records of employment contain applicants past records, list sources, employees progress, medical reports, etc or will. And coordination of client care depends on the next shift the end of each shift on patient condition list,! Csr ) • this type of reporting most commonly using 10/24/2013 ANU JAMES 33 34 of systems a. Medical history common record keeping is a permanent written communication that documents information types of records and reports in nursing ppt improve work!: Policy records and other benefit records to the use of cookies on this website goals are to process information. Some workplaces use hand-written records ; Computer-based systems ( electronic ) some organisations or employers will a... These generally fall into two categories: Policy records and common record keeping forms & amp ; computerized.... Have moved to Computer-based systems, and to show you more relevant ads combination of both chart each on! A more inclusive health information source for patients a nursing report writing is critical for any student pursuing course..., employees progress, medical reports, etc workplaces use hand-written records, list sources, employees,! Systems exist, and to provide you with relevant advertising • Problems •... For the performance of their duties to the nurses working on the shift. To toe hand-written records, turnover records and reports: documentation in nursing as... Generally fall into two categories: Policy records and operational records, history.