Nursing Records

DR TESSY MATHEW
PROFESSOR
Reports can be compiled daily, weekly, monthly,
quarterly and annually. Report summarizes the
services of the nurse and/ or the agency. Reports
may be in the form of an analysis of some aspect
of a service. 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.
 Good reports save duplication of effort and eliminate
the need for investigation to learn the facts in a
situation.
 Full reportsoften save embarrassment due
to ignorance of situation.
 Patients receive better care when reports are
thorough and give all pertinent data.
 Complete reports give a sense of
security which comes from knowing all factors in
the situation.
 It helps in efficient management of the ward.
 Reports should be made promptly if they are to
serve their purpose well.
 A good report is clear, complete, concise.
 If it is written all pertinent, identifying data are
include – the
date and time,the people concerned,
the situation, the signature of the person
making the report.
 It is clearly stated and well organized
for easy understanding.
 No extraneous material is included.
 Good oral reports are clearly expressed and
 Oral reports : Oral reports are given when the
information is for immediate use and not for
permanency. E.g. it is made by the nurse who is
assigned to patient care, to another nurse who is
 planning
Written to relieve :her.
reports Reports are to be written
when the information to be used by several
personnel, which is more or less of permanent
value, e.g. day and night reports, census,
interdepartmental reports, needed according to
situation, events and conditions.
1. Change- of- shift reports or 24
hours
 report
Provide only essential background information about
client (name, age sex, diagnosis and medical history)
but do not review all routine care procedures or task.
 Identify clients’ nursing diagnosis or health care
problems and other related causes
 Describe objective measurements or observations
about clients’ condition and response to health
problems. Stress recent change, but do not use
critical comment about clients’ behavior
 Share significant information about family members,
as it relates to clients’ problems.
 Continuouslyreview ongoing discharge plan.
Do not engage in gossip.
 Describe instructions given in teaching plan and
clients’ response.
SAMPLE OF AN CHANGE- OF- SHIFT REPORT OR 24 HOURS REPORT
WARD: NUMBER OF BEDS: DATE:
Bed NO. Name & Age Diagnosis Morning Evening Night Shift
Shift Shift
Final
Cens us
Signature
2. Transfer
reports
A transfer reports involve communication of information
about clients from the nurse on sending unit to the nurse on
the receiving unit. Nurse should include the following
 information.
Client’s name, age, primary doctor, and
 medical diagnosis. Summary of medical
 progress up to the time of transfer.
 Current health status- physical and
 psychosocial. Current nursing diagnosis
 or problems and care plan.
Any critical assessment or interventions to be

completed shortly. Needs for any special
equipments etc.
3.Incident
The nurse who witnessed the incident or who found the client
reports

at the time of incident should file the report.
 The nurse describes in concise what happened specifically
objective terms, etc.
 The nurse does not interpret or attempt to explain the cause of
 the incident.
The nurse describes objectively the clients, conditions when the
 incident was discovered.
Any measures taken by the nurse, other nurses, or doctors at
 the time of the incident are reported.
 No nurse is blamed in an incident
 report The report is submitted as
soon as possible.
The nurse should never make
photocopy of the incident report.
4. Census report
This is a report compiled daily for the number of
patients. Very often it is done at midnight and the
norms are collected by the night supervisor. The
report will show the total number of patients, the
number of admissions, discharges, transfers, births
and deaths. The nurses should remember that a
single mistake in the census figures made buy one of
the nurses make the census report of the entire
institution incorrect.
5.Birth and death
report
The nurses are responsible for sending the birth and death
reports to governmental authorities for registration within the
specified time.
6. Anecdotal report
An anecdote is brief account of some incident. Incident reports
and reports on accidents, mistakes and complaints are legal in
nature. A written record concerning some observation about a
person or about her work is called an anecdote note.
SAMPLE OF AN
Name
ACCIDENTAge: REPORT Addre
: Bed Ward ss:
no.
Date & time no. :
of accident: C.R.
No.:
Description of how the accident
occurred: Safety precautions:
Condition of the patient before
and after the accident:
Doctor’s examination findings:
Treatment ordered: witness to
accident: Signature of the
doctor:
Signature of the
nurse Unit:
1. Before anything can be written clearly, it must be
clear in one’s own mind.
2.Reports, lacking facts, may be biased or worthless.
3.Conciseness, accuracy and completeness are
essential to good
reports.
4.It is better to write several reports than one when
there is more than one main subject upon which to
report
5.Use terminology in keeping with the nature of
reports:
Short, simple, commonly used words for
nontechnical reports.
Scientific terms when issuing reports to professional
personnel.
Specific rather than general words
Use a single meaningful term rather than
phrases. 6.Observes mechanics of good

writing.
Use goods sentences and paragraphs
 Spell properly; avoid abbreviation except in
clinical charting.
 Use correct pronoun
 Don’t forget punctuation
 Be neat
8.Write report in a conversational

manner. 9.Date reports
10.If report is typed by someone
else, check it before signing it.
 The patient has a right to inspect and copy the
record after being discharged
 Failure to record significant patient information on
the medical record makes a nurse guilty of
negligence.
 Medical record must be accurate to provide a sound
basis for care planning.
 Errors in nursing charting must be corrected
promptly in a manner that leaves no doubts about
the facts.
 In reporting information about criminal acts
obtained during patient care, the nurse must reveal
FACT
Information about clients and their care must be
functional. A
record
should contain descriptive, objective information about
what a nurse sees, hears, feels and smells.
ACCURACY
A client record must be reliable. Information must be
accurate so that health team members have confidence
in it.
COMPLETENESS
The information within a recorded
entry or a report should be
complete, containing concise and thorough information
CURRENTNESS
Delays in recording or reporting can result in serious
omissions and
untimely delays for medical care or action legally, a late
entry in a chart may be interpreted on negligence.
ORGANIZATION
The nurse or nurse manager communicates
information in a logical
format or order.Health team members
understand information better when it is given in the
order in which it is occurred.
CONFIDENTIALITY
Nurses are legally and ethically obligated to keen
information about client’s illnesses and treatments
Maintaining good quality records and
reports has both immediate and long-term
benefits for staff.. In the long term it protects
individuals and teams from accusations of
poor record-keeping, and the resulting drop in
morale. It also ensures that the professional
and legal standing of nurses are not
undermined by absent or incomplete records,
if they are called to account at a hearing.

Nursing Records

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DR TESSY MATHEW

 progress up to the time of transfer.

 Current health status- physical and

 psychosocial. Current nursing diagnosis

 or problems and care plan.

Any critical assessment or interventions to be

Use a single meaningful term rather than

phrases. 6.Observes mechanics of good

 Don’t forget punctuation

8.Write report in a conversational

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