Reports

Reports

A report is a document that presents information in an organized format for a specific audience and purpose.

Definitions -

  • "Reports are oral or written exchanges of information shared between caregivers of workers in a number of ways. A report summarises the service of the personnel and of the agency."                                                                                                                                                                             (According to Jean b. 2002)
  • "Reports are information about a patient either written or oral."(According to Sr. Nancy)
  • "A report is a summary of activities or observations seen, performed or heard."(According to Potter and Perry)
  • "Reports are the effective methods of communication among the member of the team or group." (According to Dugas)

Purposes-

  • Report is an essential tool to communication.
  • As an aid in studying health condition.
  • As an aid in planning.
  • To illustrate progress in teaching goals.
  • To interpret the services to the public and to other intrested agencies.
  • To show the kind and amount of services rendered over a specific period. 

Criteria for a Good Report

  • Made promptly.
  • Clear, concise, and complete.
  • If it is written all pertinent, identifying data are included-the date and time, the people concerned, the situation, the signature of the person making the report.
  • It is clearly stated and well organized
  • Important points are emphasized.
  • In case of oral reports they are clearly expressed and presented in an interesting manner.

Importances-

  • A complete report establishes the nurse's accountability in being sure that the client's care is  uninterrupted
  • It evaluates results of nursing and medical care measures.
  • It provides a baseline for comparison during the next shift.
  • It shares significant information about family members as it relates to client problem.
  • It relates to staff significant changes in the way therapies are given.

Types of Reports  use in Hospital  setting.

  • Telephone Reports
  • Change of Shift Reports
  • Telephone Orders
  • Transfer Reports
  • Incident Reports
  • Legal Reports
  1. Telephone Reports- Health professionals frequently about a client by telephone. Nurses inform primary care providers about a change in a client's condition. The nurse receiving a telephone report should document the date and the time, the name of person giving the information and the subject of the information received.
  2. Change of Shift Reports- Is a report given to all nurses on the next shift. Its purpose is to provide continuity of care for clients by providing the new caregivers a quick summary of client needs and details of care to be given.
  3. Telephone Orders- Physicians often order a therapy for a client by telephone. While the primary care provider gives the order, write the complete order down and read it back to ensure accuracy. 
  4. Incident Reports- Occurrence reports, are used to document any unusual occurrence or accident in the delivery of client care, such as falls or medication errors. These reports are used for quality improvement and should not be used for disciplinary action against staff members. Incident reports improve the management and treatment of patients by identifying high-risk patterns and initiating in-service programs to prevent future problems.

Nurses Responsibility for Record Keeping and Reporting-

  • Keep under safe custody of nurses.
  • No individual sheet should be separated.
  • Not accessible to patients and visitors.
  • Never sent outside of the hospital without the written administrative.
  • All records and report are to be handled carefully.
  • Strangers is not permitted to read records.
  • Records are not handed over to the legal advisors without written permission of the administration.
  • Handed carefully, not destroyed.
  • Identified with bio-data of the patients such as name, age, admission number, diagnosis etc.
  • Include unremarkable measurements eg.: B.P. Pulse, temperature are within normal limits.
  • Accurate record of the patient health status on admission.
  • Accurate recording and reporting of all abnormal mode signs and symptoms observed.

Guidelines For Reporting -

  • A general method or outline of writing the report should be prepared before actually writing report.
  • As far as possible, printed forms should be used for writing the report.
  • It is necessary to collect all information and material to make the report complete.
  • Report should be comprehensive, factual and based on supervision and actual information.
  • Wording/Vocabulary of report should be simple.
  • Style of report writing should make it easy to understand.
  • Report should be arranged in such a manner that essential information can be retrived easily.
  • Important information should be underlined or expressed in a specific manner.
  • Presentation of report should be attractive and the important points should be stressed.

 

 

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