REPORTING IN NURSING

1. REPORTING IN
NURSING...
A N I L K U M A R B R , L E C T U R E R
M E D I C A L - S U R G I C A L N U R S I N G * * * * * * *

2. WITH BLESSING OF ಏಕದಃತ

3. REPORTING....
• REPORTS are oral or written exchange of
information shared between care givers (
Health care team) in a number of ways.

4. INTRODUCTION.....
• Communication is corner stone in the nursing
professional and essential part of the nursing care.
• Nurses communicate information about client’s/
patient’s so that all health care team members can
make appropriate decision making about client’s care.

5. TYPES OF REPORTING IN NURSING......
• ORAL REPORTS
• WRITTEN REPORTS

6. ORAL REPORTS....
• Oral reports are given when the information is
for immediate use and not for permanency.

7. WRITTEN REPORTS....
• Written reports are to be written when the
information to be used by several personel
which is more or less of permanent.

8. TYPES OF REPORTS IN NURSING......
• Commonly used reporting in nursing.......
1) Change-of-shift reports
2) Transfer reports
3) Incident reports and
4) Telephone reports

9. CHANGE-OF-SHIFT REPORTS...(CSR)
• This type of reporting most commonly using.
• At the end of each shift nurses report information
about their assigned client’s to the nurses working on
the next shift.
• The rport provides continuity of nursing care among
nurses who are caring for a client.

10. EXAMPLE FOR CSR...
• If first shift nurse finds a certain pain relief measure
effective for a client, it is essential that the information
be related to the next nurse carring for the client so
that pain control intervention can be continued.

11. GUIDELINES FOR GOOD CSR....
• Provide only essential background data on patient(e.g
name,age,gender,M.diagnosis, and history)
• Describe objective measurements about patient
condition an response of health problem
• Evaluate results of nursing or medical care measures.
• Be clear on priorities to which oncoming staff must
attend.

12. CONTINUE....
• Don’t review all routine care and procedure or tasks
• Don’t review all biographical data already available in
written form
• Don’t use critical comments o patient behavior

13. TRANSFER REPORTS....
• Patient’s are often Transfer from one unit to another
to receive different levels of care and treatment.
• E.g client’s transfer from an ICU or critical care units
to general nursing units when the client stable or no
longer requires such intense monitoring.

14. WHEN A GIVING A TRANSFER REPORT ,THE
FOLLOWING INFORMATION SHOULD BE GIVEN....
• Patient name,age,primary Physician and Medical
diagnosis
• Brief summary of progress up to the time of transfer
• Patient health status (physical & psychological)
• Allergies (regarding drugs and medications)
• Current treatment status (IV fluids,blood transmission
any other)
• Current nursing diagnosis or problem and care plan

15. CONTINUE.......
• Patient current vital sings and heamodynamic status (
TPR,BP HR,RR,SpO2,ECG etc)
• Any critical assessment or procedure performed
before going to transfer a client
• Need for any special equipment ( Cardiac
monitoring,sucton equipment etc)

16. INCIDENT OR OCCURRENCE
REPORTS....
• An incident is any event that is not consistent with
the routine operation of health care unit.
• incidents are commonly occur when patient under
care within hospital settings.
• Incident reports are in major part of a unit quality
improvement program

17. TYPE OF INCIDENTS
• Falling from bed or in toilet
• Neddele stick injuries
• Burns (hot Application or from other sources)
• Drugs or medications administration errors
• Mis identification of patient
• Accidental omission of ordered therapies

18. GUIDELINES TO REPORT INCIDENT
• Describe in concise what exactly happens especially in objective
terms
• Enumerate incident unit, time etc
• Explain patient condition before and after the incident (physical
& psychological)
• Describe any treatment is given after incident
• Record patient vital sings after incident

19. CONTINUE...
• No nurse should blamed in an incident reports
• As possible soon submit a repot to the authority.

20. TELEPHONE REPORTS....
• Nurse’s inform Physician or other health care team
members regarding changes in patient condition
during caring and communicate information to nurses
on other units about client’s Transfer.

21. CONTINUE...
• Telephone reports also can be utilizes a laboratory
staff or other radiological staff to providing immediate
results about patient.
• Telephone reports must contain clear,accurate,and
concise.

22. GUIDELINES FOR TELEPHONE
REPORTS.....
• It should be clearly patient name ,room, unit no,IP
number and diagnosis.
• Repeat the reports any communication error occur
• Use clarification questions to avoid misunderstanding.

23. JAI HIND,... JAI KARNATAKA...