Records and reports are practical aids for healthcare providers to document services and ensure quality care. Nursing records require clear, accurate documentation of a patient's assessment, care plan, treatment, and evaluation. Good record keeping is important for communication among providers, billing, research, and fulfilling legal and ethical obligations. Maintaining organized, confidential records according to standard procedures helps provide comprehensive care and protect all parties.
The document provides guidelines for documentation and reporting in healthcare. It discusses the purposes of documentation including communication, planning care, auditing, research, education, reimbursement, legal documentation, and healthcare analysis. It outlines various types of documentation including admission notes, change of shift notes, progress notes, transfer notes, and discharge notes. The document also discusses principles of accurate documentation including being factual, timely, legible, using accepted terminology and signatures. It provides examples of different documentation formats like narrative charting, APIE charting, and SOAP charting.
This document discusses the importance of proper nursing documentation. It notes that documentation provides a legal record of care, supports quality of care, and can defend against allegations of negligence. The document outlines objectives of documentation and legal pitfalls to avoid like improper abbreviations, late entries, and illegible writing. Tips are provided like documenting immediately after care, using approved abbreviations, and following facility policies. The significance of documentation in terms of legal, communication, and financial reasons is also discussed.
Documentation and reporting in healthcare involves recording information in patient records and communicating information to other healthcare providers. Patient records contain key identifying and clinical information to provide an accurate record of a patient's care over time. Records are used for communication between providers, planning care, quality assurance, research, education, reimbursement, and legal documentation. Effective documentation and reporting requires following guidelines such as recording factual, dated, legible, permanent, unambiguous information in the proper sequence and manner according to healthcare organization policies.
This document discusses nursing records and reports. It defines records as permanent documentation of a client's health care and reports as summaries of services provided. Records are used to guide care, ensure continuity, and protect from legal issues. They must be factual, objective, dated, and signed. Reports are shared between caregivers and summarize services. Good reports are clear, concise, and prompt. The document outlines the types and importance of both nursing records and reports in hospital and community settings.
Documentation & Reporting In Nursing Practice.pptxDipon11
This document discusses documentation and reporting in nursing practice. It provides guidelines for proper documentation including using dates, times, legible writing, correct spelling, permanence, accuracy, sequence, appropriateness, completeness, conciseness, organization, and signatures. Documentation serves several purposes such as providing a record of care, guiding reimbursement, and serving as potential legal evidence. Different types of reports in nursing are also outlined including change of shift reports, transfer reports, and incident reports.
The document discusses various aspects of documentation and reporting in healthcare settings. It covers the purposes of documentation including communication, legal documentation, research, statistics, education, audit and quality assurance, and planning client care. It describes different types of client records including source oriented, narrative charting, problem-oriented, and computerized records. It provides guidelines for documentation including confidentiality, accuracy, brevity, appropriateness, completeness, and use of approved terminology and abbreviations. It also discusses different methods of documentation like SOAPIE notes, PIE charting, FOCUS charting, and kardex. Finally, it covers different types of reporting including change of shift reports, telephone reports, and incident reports.
Nursing documentation is important for several reasons:
1) It helps communicate between the healthcare team and prevents fragmentation, repetition, and delays in patient care.
2) Nursing documentation is used to establish nursing care plans and for auditing, research, education, and reimbursement purposes.
3) Documentation provides a comprehensive view of the patient's condition and treatment and can be used as legal evidence in court cases.
The document provides guidelines for documentation and reporting in healthcare. It discusses the purposes of documentation including communication, planning care, auditing, research, education, reimbursement, legal documentation, and healthcare analysis. It outlines various types of documentation including admission notes, change of shift notes, progress notes, transfer notes, and discharge notes. The document also discusses principles of accurate documentation including being factual, timely, legible, using accepted terminology and signatures. It provides examples of different documentation formats like narrative charting, APIE charting, and SOAP charting.
This document discusses the importance of proper nursing documentation. It notes that documentation provides a legal record of care, supports quality of care, and can defend against allegations of negligence. The document outlines objectives of documentation and legal pitfalls to avoid like improper abbreviations, late entries, and illegible writing. Tips are provided like documenting immediately after care, using approved abbreviations, and following facility policies. The significance of documentation in terms of legal, communication, and financial reasons is also discussed.
Documentation and reporting in healthcare involves recording information in patient records and communicating information to other healthcare providers. Patient records contain key identifying and clinical information to provide an accurate record of a patient's care over time. Records are used for communication between providers, planning care, quality assurance, research, education, reimbursement, and legal documentation. Effective documentation and reporting requires following guidelines such as recording factual, dated, legible, permanent, unambiguous information in the proper sequence and manner according to healthcare organization policies.
This document discusses nursing records and reports. It defines records as permanent documentation of a client's health care and reports as summaries of services provided. Records are used to guide care, ensure continuity, and protect from legal issues. They must be factual, objective, dated, and signed. Reports are shared between caregivers and summarize services. Good reports are clear, concise, and prompt. The document outlines the types and importance of both nursing records and reports in hospital and community settings.
Documentation & Reporting In Nursing Practice.pptxDipon11
This document discusses documentation and reporting in nursing practice. It provides guidelines for proper documentation including using dates, times, legible writing, correct spelling, permanence, accuracy, sequence, appropriateness, completeness, conciseness, organization, and signatures. Documentation serves several purposes such as providing a record of care, guiding reimbursement, and serving as potential legal evidence. Different types of reports in nursing are also outlined including change of shift reports, transfer reports, and incident reports.
The document discusses various aspects of documentation and reporting in healthcare settings. It covers the purposes of documentation including communication, legal documentation, research, statistics, education, audit and quality assurance, and planning client care. It describes different types of client records including source oriented, narrative charting, problem-oriented, and computerized records. It provides guidelines for documentation including confidentiality, accuracy, brevity, appropriateness, completeness, and use of approved terminology and abbreviations. It also discusses different methods of documentation like SOAPIE notes, PIE charting, FOCUS charting, and kardex. Finally, it covers different types of reporting including change of shift reports, telephone reports, and incident reports.
Nursing documentation is important for several reasons:
1) It helps communicate between the healthcare team and prevents fragmentation, repetition, and delays in patient care.
2) Nursing documentation is used to establish nursing care plans and for auditing, research, education, and reimbursement purposes.
3) Documentation provides a comprehensive view of the patient's condition and treatment and can be used as legal evidence in court cases.
The document discusses principles and types of documentation in the ICU. It notes that documentation ensures continuity of care, provides legal protection, and records patient status, tests, treatments, and progress. Records must be written clearly, accurately, legibly, and in chronological order. Types of records include patient records, nurse and doctor notes, charts, intake/output records, and various logs. Records provide accurate information to guide care and have legal, educational, research, and administrative value. Proper care and storage of records is also outlined.
The document discusses principles and types of documentation in the ICU. It notes that documentation ensures continuity of care, provides legal protection, and records patient status, tests, treatments, and progress. Records must be written clearly, accurately, legibly, and in chronological order. Types of records include patient records, nurse and doctor notes, charts, intake/output records, and various logs. Records provide accurate information to guide care and have legal, educational, research, and administrative value. Proper care and storage of records is also outlined.
This document provides guidelines for doctors on safe clinical practices and handling medico-legal cases. It discusses the importance of thorough documentation, including maintaining proper patient records, obtaining informed consent, and notifying police in certain cases. Good record keeping is emphasized as the best defense against allegations of negligence. The roles and responsibilities of doctors and staff are also covered.
Documentation and reporting in healthcare involves recording patient information in charts and providing communication to other healthcare professionals. Records can be either written or electronic and contain things like assessments, care plans, treatments, and test results. Reports convey information orally, in writing, or electronically and are used to communicate changes in a patient's condition between shifts or departments. Maintaining accurate documentation is important for continuity of care, legal purposes, reimbursement, and analyzing health outcomes. Proper communication between all members of the healthcare team through documentation and reporting is essential for providing comprehensive, high-quality patient care.
This document discusses the importance of maintaining accurate records and reports in community health nursing. It defines records and reports, and outlines their key functions which include improving accountability, supporting patient care decisions, and promoting continuity of care. The document also describes various types of clinical records used in community health nursing, such as handwritten notes, health records, and laboratory reports. Finally, it provides examples of specific records and registers maintained by community health nurses, such as immunization records, antenatal health records, and staff nurse report books.
documentation and reporting for nursing students. this session deals with important of proper documentation and its legal implications, thus can reduce errors.
Documentation and reporting are important communication techniques for healthcare providers. Documentation provides a written record of interactions between healthcare professionals and clients, as well as test results, treatments, and client responses. Reporting involves sharing client care information between two or more people. The purposes of client records include communication, legal documentation, research, education, quality assurance, and reimbursement. Effective documentation is accurate, complete, organized, and uses common terminology and abbreviations. Common types of records include nursing assessments, care plans, flow charts, and progress notes.
This document discusses electronic medical records (EMRs) and electronic health records (EHRs). EMRs contain patient medical data entered by doctors, while EHRs also include additional information like demographics and test results. EMRs are part of EHRs and are used for registration, billing, screenings, and scheduling. EHRs provide benefits like comprehensive patient histories and improved care, but also risks like security issues, hacking vulnerabilities, and data loss. Taking an accurate patient history is important for determining the cause of illness, and involves listening carefully and asking common sense questions. History taking is both an art and a science, requiring social and medical skills to build patient confidence and direct objective principles for maximum benefit.
Dear all,
Recording & Reporting are very important in the nursing profession. As a nurse, we have to be very conscious of it to prevent further complications.
The community and patients tend to forget that the clinicians and other healthcare personnel are also human like them. Every human makes an error while performing his or her task, accurately reporting the performance and due to general forgetfulness. However, the consequences of errors in medical practice are potentially serious for both patients and doctors alike.
This document discusses records, reports, and documentation in nursing. It defines records as permanent documentation of a client's health information, while reports are oral or written communications between caregivers. Records are important for continuity of care, research, and legal purposes. They must be accurate, objective, and kept confidential. Nurses are responsible for maintaining different types of records like patient, staff, and ward records. Reports include shift changes, transfers, and statistical summaries. Good documentation follows principles like being factual, relevant, and updated in a timely manner.
documentation and reporting is the basic of nursing care and can be used in all health care setting why, how and when to documented that is described in the ppt the nurses and all health care professional for study, examination and application of this knowledge into their clinical practice
The document provides guidelines for proper nursing documentation. It discusses principles of documentation including being factual, accurate, complete, concise, and using accepted terminology and spelling. It emphasizes documenting in chronological order, with date, time, and signature. Corrections should have single line drawn through and initialed rather than erased. Documentation must maintain patient confidentiality and nurses are accountable for their own entries.
Focus charting describes documenting from the patient's perspective about their current status, progress towards goals, and response to interventions. It uses a focus column that incorporates the patient's concerns, therapies, responses, and functional health. The focus charting includes data about observations, actions describing nursing interventions, and response describing the patient outcome. The purpose is to bring focus back to the patient and their priorities in a holistic way.
Records created by healthcare workers are considered health records under UK law. Health records must be factual, consistent, accurate, dated, timed, signed, and avoid jargon. Poor record keeping can lead to issues like mistakes in care, complaints, disciplinary action, and even criminal proceedings. The main barrier to good record keeping is a lack of time. Records made by non-registered staff must be regularly countersigned by their supervisor.
This document provides an overview of the scope and responsibilities of a Patient Care Technician (PCT) program, including documentation. It outlines that PCTs help patients with daily needs like cleaning and medications. They are responsible for assessing patient health, vital signs, and notifying nurses of changes. PCTs must accurately document all treatments, patient conditions, and concerns in medical records. The document defines documentation, explains its importance for maintaining patient records and legal protection. It lists characteristics of proper documentation such as being accurate, complete, timely, and authenticated without errors.
Documentation-and-Reporting students sharing.pptAnju Kumawat
This document discusses documentation, recording, and reporting in healthcare. It covers the purposes of documentation which include communication, legal records, audits, research, and education. It describes different types of records like patient records, nursing service records, and nursing education records. Guidelines are provided for recording, including principles of record writing, common record keeping forms, and computerized documentation. Methods of reporting include narrative charting and problem-oriented charting. The purposes of reporting to ensure communication among the healthcare team is also covered.
This document discusses documentation and reporting in healthcare. It covers the purposes of documentation such as communication, legal records, audits, research, and education. It describes different types of records like patient records, nursing records, and academic records. It discusses guidelines for accurate, complete, confidential, and factual documentation. It also covers various types of reports like change of shift reports, transfer reports, and incident reports. The document provides examples of documentation forms and emphasizes the importance of minimizing legal liabilities through thorough documentation.
This document discusses documentation and reporting in healthcare. It defines documentation as communicating facts in writing over time to maintain a history of events. Recording and reporting are also forms of documentation. The purposes of documentation include communication, legal records, audits, research, education, and continuity of care. Different types of records are discussed, including patient records, nursing service records, and nursing education records. Principles of clear and accurate documentation are presented. The document also covers types of reporting, such as shift change reports and transfer reports.
LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
core of India. Mirzapur, with its varied terrains and abundant biodiversity, offers an optimal
environment for investigating the changes in vegetation cover dynamics. Our study utilizes
advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
analyze the transformations that have taken place over the course of a decade.
The complex relationship between human activities and the environment has been the focus
of extensive research and worry. As the global community grapples with swift urbanization,
population expansion, and economic progress, the effects on natural ecosystems are becoming
more evident. A crucial element of this impact is the alteration of vegetation cover, which plays a
significant role in maintaining the ecological equilibrium of our planet.Land serves as the foundation for all human activities and provides the necessary materials for
these activities. As the most crucial natural resource, its utilization by humans results in different
'Land uses,' which are determined by both human activities and the physical characteristics of the
land.
The utilization of land is impacted by human needs and environmental factors. In countries
like India, rapid population growth and the emphasis on extensive resource exploitation can lead
to significant land degradation, adversely affecting the region's land cover.
Therefore, human intervention has significantly influenced land use patterns over many
centuries, evolving its structure over time and space. In the present era, these changes have
accelerated due to factors such as agriculture and urbanization. Information regarding land use and
cover is essential for various planning and management tasks related to the Earth's surface,
providing crucial environmental data for scientific, resource management, policy purposes, and
diverse human activities.
Accurate understanding of land use and cover is imperative for the development planning
of any area. Consequently, a wide range of professionals, including earth system scientists, land
and water managers, and urban planners, are interested in obtaining data on land use and cover
changes, conversion trends, and other related patterns. The spatial dimensions of land use and
cover support policymakers and scientists in making well-informed decisions, as alterations in
these patterns indicate shifts in economic and social conditions. Monitoring such changes with the
help of Advanced technologies like Remote Sensing and Geographic Information Systems is
crucial for coordinated efforts across different administrative levels. Advanced technologies like
Remote Sensing and Geographic Information Systems
9
Changes in vegetation cover refer to variations in the distribution, composition, and overall
structure of plant communities across different temporal and spatial scales. These changes can
occur natural.
The document discusses principles and types of documentation in the ICU. It notes that documentation ensures continuity of care, provides legal protection, and records patient status, tests, treatments, and progress. Records must be written clearly, accurately, legibly, and in chronological order. Types of records include patient records, nurse and doctor notes, charts, intake/output records, and various logs. Records provide accurate information to guide care and have legal, educational, research, and administrative value. Proper care and storage of records is also outlined.
The document discusses principles and types of documentation in the ICU. It notes that documentation ensures continuity of care, provides legal protection, and records patient status, tests, treatments, and progress. Records must be written clearly, accurately, legibly, and in chronological order. Types of records include patient records, nurse and doctor notes, charts, intake/output records, and various logs. Records provide accurate information to guide care and have legal, educational, research, and administrative value. Proper care and storage of records is also outlined.
This document provides guidelines for doctors on safe clinical practices and handling medico-legal cases. It discusses the importance of thorough documentation, including maintaining proper patient records, obtaining informed consent, and notifying police in certain cases. Good record keeping is emphasized as the best defense against allegations of negligence. The roles and responsibilities of doctors and staff are also covered.
Documentation and reporting in healthcare involves recording patient information in charts and providing communication to other healthcare professionals. Records can be either written or electronic and contain things like assessments, care plans, treatments, and test results. Reports convey information orally, in writing, or electronically and are used to communicate changes in a patient's condition between shifts or departments. Maintaining accurate documentation is important for continuity of care, legal purposes, reimbursement, and analyzing health outcomes. Proper communication between all members of the healthcare team through documentation and reporting is essential for providing comprehensive, high-quality patient care.
This document discusses the importance of maintaining accurate records and reports in community health nursing. It defines records and reports, and outlines their key functions which include improving accountability, supporting patient care decisions, and promoting continuity of care. The document also describes various types of clinical records used in community health nursing, such as handwritten notes, health records, and laboratory reports. Finally, it provides examples of specific records and registers maintained by community health nurses, such as immunization records, antenatal health records, and staff nurse report books.
documentation and reporting for nursing students. this session deals with important of proper documentation and its legal implications, thus can reduce errors.
Documentation and reporting are important communication techniques for healthcare providers. Documentation provides a written record of interactions between healthcare professionals and clients, as well as test results, treatments, and client responses. Reporting involves sharing client care information between two or more people. The purposes of client records include communication, legal documentation, research, education, quality assurance, and reimbursement. Effective documentation is accurate, complete, organized, and uses common terminology and abbreviations. Common types of records include nursing assessments, care plans, flow charts, and progress notes.
This document discusses electronic medical records (EMRs) and electronic health records (EHRs). EMRs contain patient medical data entered by doctors, while EHRs also include additional information like demographics and test results. EMRs are part of EHRs and are used for registration, billing, screenings, and scheduling. EHRs provide benefits like comprehensive patient histories and improved care, but also risks like security issues, hacking vulnerabilities, and data loss. Taking an accurate patient history is important for determining the cause of illness, and involves listening carefully and asking common sense questions. History taking is both an art and a science, requiring social and medical skills to build patient confidence and direct objective principles for maximum benefit.
Dear all,
Recording & Reporting are very important in the nursing profession. As a nurse, we have to be very conscious of it to prevent further complications.
The community and patients tend to forget that the clinicians and other healthcare personnel are also human like them. Every human makes an error while performing his or her task, accurately reporting the performance and due to general forgetfulness. However, the consequences of errors in medical practice are potentially serious for both patients and doctors alike.
This document discusses records, reports, and documentation in nursing. It defines records as permanent documentation of a client's health information, while reports are oral or written communications between caregivers. Records are important for continuity of care, research, and legal purposes. They must be accurate, objective, and kept confidential. Nurses are responsible for maintaining different types of records like patient, staff, and ward records. Reports include shift changes, transfers, and statistical summaries. Good documentation follows principles like being factual, relevant, and updated in a timely manner.
documentation and reporting is the basic of nursing care and can be used in all health care setting why, how and when to documented that is described in the ppt the nurses and all health care professional for study, examination and application of this knowledge into their clinical practice
The document provides guidelines for proper nursing documentation. It discusses principles of documentation including being factual, accurate, complete, concise, and using accepted terminology and spelling. It emphasizes documenting in chronological order, with date, time, and signature. Corrections should have single line drawn through and initialed rather than erased. Documentation must maintain patient confidentiality and nurses are accountable for their own entries.
Focus charting describes documenting from the patient's perspective about their current status, progress towards goals, and response to interventions. It uses a focus column that incorporates the patient's concerns, therapies, responses, and functional health. The focus charting includes data about observations, actions describing nursing interventions, and response describing the patient outcome. The purpose is to bring focus back to the patient and their priorities in a holistic way.
Records created by healthcare workers are considered health records under UK law. Health records must be factual, consistent, accurate, dated, timed, signed, and avoid jargon. Poor record keeping can lead to issues like mistakes in care, complaints, disciplinary action, and even criminal proceedings. The main barrier to good record keeping is a lack of time. Records made by non-registered staff must be regularly countersigned by their supervisor.
This document provides an overview of the scope and responsibilities of a Patient Care Technician (PCT) program, including documentation. It outlines that PCTs help patients with daily needs like cleaning and medications. They are responsible for assessing patient health, vital signs, and notifying nurses of changes. PCTs must accurately document all treatments, patient conditions, and concerns in medical records. The document defines documentation, explains its importance for maintaining patient records and legal protection. It lists characteristics of proper documentation such as being accurate, complete, timely, and authenticated without errors.
Documentation-and-Reporting students sharing.pptAnju Kumawat
This document discusses documentation, recording, and reporting in healthcare. It covers the purposes of documentation which include communication, legal records, audits, research, and education. It describes different types of records like patient records, nursing service records, and nursing education records. Guidelines are provided for recording, including principles of record writing, common record keeping forms, and computerized documentation. Methods of reporting include narrative charting and problem-oriented charting. The purposes of reporting to ensure communication among the healthcare team is also covered.
This document discusses documentation and reporting in healthcare. It covers the purposes of documentation such as communication, legal records, audits, research, and education. It describes different types of records like patient records, nursing records, and academic records. It discusses guidelines for accurate, complete, confidential, and factual documentation. It also covers various types of reports like change of shift reports, transfer reports, and incident reports. The document provides examples of documentation forms and emphasizes the importance of minimizing legal liabilities through thorough documentation.
This document discusses documentation and reporting in healthcare. It defines documentation as communicating facts in writing over time to maintain a history of events. Recording and reporting are also forms of documentation. The purposes of documentation include communication, legal records, audits, research, education, and continuity of care. Different types of records are discussed, including patient records, nursing service records, and nursing education records. Principles of clear and accurate documentation are presented. The document also covers types of reporting, such as shift change reports and transfer reports.
Ähnlich wie Records and reports documtation 1st bsc ppt.pptx (20)
LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
core of India. Mirzapur, with its varied terrains and abundant biodiversity, offers an optimal
environment for investigating the changes in vegetation cover dynamics. Our study utilizes
advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
analyze the transformations that have taken place over the course of a decade.
The complex relationship between human activities and the environment has been the focus
of extensive research and worry. As the global community grapples with swift urbanization,
population expansion, and economic progress, the effects on natural ecosystems are becoming
more evident. A crucial element of this impact is the alteration of vegetation cover, which plays a
significant role in maintaining the ecological equilibrium of our planet.Land serves as the foundation for all human activities and provides the necessary materials for
these activities. As the most crucial natural resource, its utilization by humans results in different
'Land uses,' which are determined by both human activities and the physical characteristics of the
land.
The utilization of land is impacted by human needs and environmental factors. In countries
like India, rapid population growth and the emphasis on extensive resource exploitation can lead
to significant land degradation, adversely affecting the region's land cover.
Therefore, human intervention has significantly influenced land use patterns over many
centuries, evolving its structure over time and space. In the present era, these changes have
accelerated due to factors such as agriculture and urbanization. Information regarding land use and
cover is essential for various planning and management tasks related to the Earth's surface,
providing crucial environmental data for scientific, resource management, policy purposes, and
diverse human activities.
Accurate understanding of land use and cover is imperative for the development planning
of any area. Consequently, a wide range of professionals, including earth system scientists, land
and water managers, and urban planners, are interested in obtaining data on land use and cover
changes, conversion trends, and other related patterns. The spatial dimensions of land use and
cover support policymakers and scientists in making well-informed decisions, as alterations in
these patterns indicate shifts in economic and social conditions. Monitoring such changes with the
help of Advanced technologies like Remote Sensing and Geographic Information Systems is
crucial for coordinated efforts across different administrative levels. Advanced technologies like
Remote Sensing and Geographic Information Systems
9
Changes in vegetation cover refer to variations in the distribution, composition, and overall
structure of plant communities across different temporal and spatial scales. These changes can
occur natural.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
Leveraging Generative AI to Drive Nonprofit InnovationTechSoup
In this webinar, participants learned how to utilize Generative AI to streamline operations and elevate member engagement. Amazon Web Service experts provided a customer specific use cases and dived into low/no-code tools that are quick and easy to deploy through Amazon Web Service (AWS.)
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
This presentation was provided by Steph Pollock of The American Psychological Association’s Journals Program, and Damita Snow, of The American Society of Civil Engineers (ASCE), for the initial session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session One: 'Setting Expectations: a DEIA Primer,' was held June 6, 2024.
বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
তাই একজন নাগরিক হিসাবে এই তথ্য গুলো আপনার জানা প্রয়োজন ...।
বিসিএস ও ব্যাংক এর লিখিত পরীক্ষা ...+এছাড়া মাধ্যমিক ও উচ্চমাধ্যমিকের স্টুডেন্টদের জন্য অনেক কাজে আসবে ...
Beyond Degrees - Empowering the Workforce in the Context of Skills-First.pptxEduSkills OECD
Iván Bornacelly, Policy Analyst at the OECD Centre for Skills, OECD, presents at the webinar 'Tackling job market gaps with a skills-first approach' on 12 June 2024
2. Introduction
• This are practical and indispensable aid to doctor ,nurse ,paramedical people
in giving best possible service to individual, family, community.
• Documentation means Anything written or presented that is relied in as a
record of proof for authorized person.
3. Terms
• Standing order (A "standing order" is a prewritten medication order and specific instructions from the
licensed independent practitioner to administer a medication to a person in clearly defined circumstances)
• Family folder
• Record
• Informed consent
• Incidental reports
• Contract
• Documentation
• protocol
4. Definition
• RECORDS are formal ,legal individual ,family and community.
• It’s a documentation, anything written, printed that is relied on as a record proof
for authorized persons
• REPORTS offer summery of activities or observations seen ,performed or heard is
exchanged among health care team, members, family.
• Its oral / written document.
5. Purposes of records
• Communication
• Financial billing
• Educational
• Assessment
• Research
• Auditing and monitoring
• legal
6. Purposes of reports
• To show kind ,amount of services rendered over a specific period.
• It helps to illustrate progress
• Aid in studying in reaching goals.
• Aid in planning
• Helps to interpret services to public.
7. Principles of recording
• Clear , accurate, appropriate,
• Confidential
• Not to make errors
• Write in black ink/type it.
• Proper order with date
• Immediate recording should be done.
• Uniformity of services
• Provide periodic summery
• Relevant facts, brief and accurate.
8. Care of records
• Safe custody
• No separated sheets
• Should be in Safe place
• Should be never send out of hospital.
• Should be handled carefully.
• Should not be given to legal people.
• Should be kept in confidence all information.
9. Principles of reporting
• Should be truthful, accurate.
• Confidential, brief
Should be
• avoid duplication
Should be
• to relive personnel to plan future care of pt.
• Pt. receives better care.
10. Types of records
• Cumulative or Continuous records
• Family records
• Anecdotal records
• Clinical records
• Doctor order sheet
• Nurse
11. Types of reports
• Oral report
• Written report
• 24 hour report
• Census report
• Accidental report
• Change of shift report
12. • Transfer accidental report
• Transfer accidental report
• Change of shift report
• Transfer accidental report
• Transfer reports
13. • In the busy working day of a nurse, with the many urgent demands on your time,
you may feel that keeping nursing records is a distraction from the real work of
nursing: looking after your patients.
• This cannot be more wrong! Keeping good records is part of the nursing care we
give to our patients.
• It is nearly impossible to remember everything you did and everything that
happened on a shift. Without clear and accurate nursing records for each patient,
our handover to the next team of nurses will be incomplete. Needless to say, this
can affect the wellbeing of patients.
14. • in fact, the quality of our record keeping can be a good (or bad) reflection of
the standard of care we give to our patients: careful, neat, and accurate
patient records are the hallmarks of a caring and responsible nurse, but
poorly written records can lead to doubts about the quality of a nurse's work.
15. • Another important consideration is the legal significance of nursing records.
If a patient brings a complaint, your nursing records are the only proof that
you have fulfilled your duty of care to the patient.
• According to the law in many countries, if care or treatment due to a patient
is not recorded, it can be assumed that it has not happened.
• Poor record keeping can therefore mean you are found negligent, even if
you are sure you provided the correct care - and this may cause you to lose
your right to practise.
16. Who is responsible to keep records
• Anyone on the nursing team who provides patient care can contribute to
record keeping. However, if you are a qualified or senior nurse supervising
unqualified colleagues, you should assume responsibility for providing
guidance on documentation.
17.
18. How to keep good nursing records
• The patient's record must provide an accurate, current, objective, comprehensive, but
concise, account of his/her stay in hospital.
• Traditionally, nursing records are hand-written. Do not assume that electronic record
keeping is necessary.
• Use a standardised form. This will help to ensure consistency and improve the quality of the
written record.
• There should be a systematic approach to providing nursing care (the nursing process) and
this should be documented consistently.
• The nursing record should include assessment, planning, implementation, and evaluation of
care.
19. • Ensure the record begins with an identification sheet. This contains the patient's personal
data: name, age, address, next of kin, carer, and so on. All continuation sheets must show
the full name of the patient.
• Ensure a supply of continuation sheets is available.
• Date and sign each entry, giving your full name. Give the time, using the 24-hour clock
system. For example, write 14:00 instead of 2 pm.
• Write in dark ink (preferably black ink), never in pencil, and keep records out of direct
sunlight. This will help to ensure they do not fade and cannot be erased.
• On admission, record the patient's visual acuity, blood pressure, pulse, temperature, and
respiration, as well as the results of any tests.
20. • State the diagnosis clearly, as well as any other problem the patient is
currently experiencing.
• Record all medication given to the patient and sign the prescription sheet.
• Record all relevant observations in the patient's nursing record, as well as on
any charts, e.g., blood pressure charts or intraocular pressure phasing charts.
File the charts in the medical notes when the patient is discharged.
• Ensure that the consent form for surgery, signed clearly by the patient, is
included in the patient's records.
21. • Include a nursing checklist to ensure the patient is prepared for any
scheduled surgery.
• Note all plans made for the patient's discharge, e.g., whether the patient or
career is competent at instilling the prescribed eye drops and whether they
understand details of follow-up appointments.
22. Writing tips
• Ensure the statements are factual and recorded in consecutive order, as they
happen. Only record what you, as the nurse, see, hear, or do.
• Do not use jargon, meaningless phrases, or personal opinions (e.g., “the patient's
vision appears blurred” or “the patient's vision appears to be improving”).
• If you want to make a comment about changes in the patient's vision, check the
visual acuity and record it.
• Do not use an abbreviation unless you are sure that it is commonly understood and
in general use. For example, BP and VA are in general use and would be safe to use
on records when commenting on blood pressure and visual acuity, respectively.
23. • Do not speculate, make offensive statements, or use humour about the patient.
Patients have the right to see their records!
• If you make an error, cross it out with one clear line through it, and sign. Do not
use sticky labels or correction fluid.
• Write legibly and in clear, short sentences.
• Remember, some information you have been given by the patient may be
confidential. Think carefully and decide whether it is necessary to record it in
writing where anyone may be able to read it; all members of the eye care team, and
also the patient and relatives, have a right to access nursing records.
24. Looking after nursing records
• Keep the nursing records in a place where they can be accessed easily; preferably
near to where the nursing team meet at shift change times.
• This will ensure that records are available for handover sessions and also that they
are easily accessible to the rest of the eye care team.
• The handover may take place with the patient present, if appropriate.
• Indeed, nursing records can only be accurate if patients have been involved in
decision making related to their care.
• File the nursing records in the medical notes folder on discharge. Ensure that the
whole team knows if nursing records are stored elsewhere.
25. How can nursing records contribute to good
care?
• Accurate records will contain observations of clinical outcomes, for example, how
an elderly patient has benefited from his or her cataract operation or how skilled the
patient is at instilling eye drops before discharge.
• Such information can be used in clinical audit and reports on clinical activity.
• This contributes to research and performance data which can be used to monitor
improvement in service delivery and outcomes, all of which ultimately contributes
to better care.
• It is not only medical notes that are important; well-written nursing records will
provide qualitative comment on treatment outcomes.