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    Documentation, Nursing Rounds, Manual & Protocol

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    SUNNY__SIJI
    This document discusses nursing documentation, including records, reports, nursing rounds, manuals, and protocols. It provides information on: 1. The purposes of records which include providing accurate patient care details, evaluating quality of care, and serving legal purposes. 2. The types of records maintained such as treatment books, admission records, and laboratory reports. 3. The purposes of reports which include communicating patient status between shifts and maintaining continuity of care. 4. The types of reports including those among healthcare team members and between nurses and physicians. 5. The purposes and advantages of nursing rounds/visits which include assessing patients and teaching staff and students. So in summary, the document outlines the

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    Documentation, Nursing Rounds, Manual & Protocol

    Uploaded by

    SUNNY__SIJI
    242 views22 pages
    This document discusses nursing documentation, including records, reports, nursing rounds, manuals, and protocols. It provides information on: 1. The purposes of records which include providing accurate patient care details, evaluating quality of care, and serving legal purposes. 2. The types of records maintained such as treatment books, admission records, and laboratory reports. 3. The purposes of reports which include communicating patient status between shifts and maintaining continuity of care. 4. The types of reports including those among healthcare team members and between nurses and physicians. 5. The purposes and advantages of nursing rounds/visits which include assessing patients and teaching staff and students. So in summary, the document outlines the

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    DOCUMENTATION IN NURSING

    Original Title

    Documentation

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    This document discusses nursing documentation, including records, reports, nursing rounds, manuals, and protocols. It provides information on: 1. The purposes of records which include providing accurate patient care details, evaluating quality of care, and serving legal purposes. 2. The types of records maintained such as treatment books, admission records, and laboratory reports. 3. The purposes of reports which include communicating patient status between shifts and maintaining continuity of care. 4. The types of reports including those among healthcare team members and between nurses and physicians. 5. The purposes and advantages of nursing rounds/visits which include assessing patients and teaching staff and students. So in summary, the document outlines the

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    242 views22 pages

    Documentation, Nursing Rounds, Manual & Protocol

    Uploaded by

    SUNNY__SIJI
    This document discusses nursing documentation, including records, reports, nursing rounds, manuals, and protocols. It provides information on: 1. The purposes of records which include providing accurate patient care details, evaluating quality of care, and serving legal purposes. 2. The types of records maintained such as treatment books, admission records, and laboratory reports. 3. The purposes of reports which include communicating patient status between shifts and maintaining continuity of care. 4. The types of reports including those among healthcare team members and between nurses and physicians. 5. The purposes and advantages of nursing rounds/visits which include assessing patients and teaching staff and students. So in summary, the document outlines the

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    of 22

    DOCUMENTATION,

    NURSING ROUNDS, MANUAL


    & PROTOCOL

    RECORDS

    Records

    are

    administrative

    formally
    tools

    permanently

    legal,
    that

    document

    information relevant to direct or


    indirect patient care.

    PURPOSES OF RECORDS

    It provides an accurate and detailed account of treatment and care given to the

    patient.

    They evaluate quality patient care

    They can be used as a reference material for research

    Records are tools of communication among the health care team members

    Records also have a legal value. The records safeguard the patients, nurses,
    doctors and the hospital. It serves as evidence that the patient care is
    intelligently managed.

    They help the nursing and medical students in their clinical experience and
    provide data for care studies.

    PURPOSES OF RECORDS

    It serves as a follow up of the course of the disease and future care

    A record of illness and treatment saves duplication of work in the future care
    especially when the patient is transferred from one department to another or
    from one institution to another or when an attending physician is transferred
    or other personnel takes charge.

    The patients record, registers and reports furnish the vital statistics and give
    information needed to evaluate the health care services rendered by the
    hospital to the community.

    Data taken from the patients record points out the health problems of the
    country and it also provides a baseline in which local, state, national and
    international health services can be planned.

    TYPES OF RECORDS

    Report book

    Treatment book

    Duty roster for staff

    Stock register

    Admission and discharge book

    Complaint book for maintenance and

    and respiration

    Indent register

    Reports of laboratory examinations

    Diet register

    Consent form for operations and


    anesthesia

    repairs

    Graphic charts of temperature, pulse

    Records

    of

    anesthesia,

    physiotherapy, occupational therapy


    and other special treatments
    Physicians order sheets

    REPORTS
    A report consists of oral or written exchanges of

    information shared between members in the health care


    team.
    A report is a system of communication aimed at

    transferring essential information necessary for safe and

    holistic patient care.

    PURPOSES OF REPORTS

    To communicate progress of the patients health status to all nurses in

    different shifts

    To prepare staff members for their days work

    To ensure that all the staff members have the same information

    To maintain continuity of care from one shift to another

    To illustrate progress in reaching goals

    To coordinate care among various health care personnel

    To promote accuracy in the provision of quality care and prevent errors

    To effectively manage time and avoid duplication or overlapping of activities

    TYPES OF REPORTS

    Reports among the members of the health team

    Each member of the nursing team gives a detailed report to the team leader/

    staff in- charge at the end of the shift. A report is given when the responsibility
    for patient care is turned over from one person to another

    Reports between the head nurse and her assistant

    Reports between the head nurse and the nursing superintendent

    The day, evening and night reports are sent to the nursing superintendent at

    regular intervals. This includes the reports of all seriously ill patients, the

    newly admitted patients, patients who had surgery, patients who had accidents,
    census etc. the report may also contain the problems that are met with the
    patient care. E.g. inadequate supply of articles.

    TYPES OF REPORTS
    Reports to the physician

    The nurses provide report of any unusual changes in the patients

    condition like medication side effects, results of any investigations etc.


    Reports on accidents, mistakes and complaints

    A detailed report on mistakes, accidents and complaints is sent to the

    concerned authority such that such incidents are prevented in the future
    and there is improvement in patient care.

    NURSING ROUNDS/VISITS
    Nursing

    conducted

    rounds
    by

    the

    are
    head

    nurse/ nurse teacher with

    her staff members/ students


    for a clear understanding of
    the disease and the effect of

    nursing
    patient.

    care

    for

    each

    PURPOSE OF NURSING ROUNDS/VISITS


    To assess the physical and mental condition of the patients and

    the progress made each day.


    To observe the work of staff
    To make specific observations of patients e.g. wounds, drainage,

    bleeding etc.
    To introduce patients to the staff members i.e. the patients

    history, treatment and all the medical aspects of his care.


    To formulate a plan of action for care of patients

    PURPOSE OF NURSING ROUNDS/VISITS

    To evaluate the results of treatment and patient satisfaction

    To ensure that safety measures are employed for patients and personnel

    To orient the staff nurse/ nursing students towards the health status of their
    patients

    To teach nursing students and hospital staff regarding specific conditions

    To initiate any modifications in nursing action

    To ensure the safety and working condition of the equipments kept in the

    patients bedside

    ADVANTAGES OF NURSING
    ROUNDS/VISITS
    They offer a real life learning situation to both student nurses
    as well as staff
    It helps in the evaluation of nursing activity
    They help in orienting a staff nurse/ student nurse to the
    patient

    The hurdles faced by nurse in implementing treatment can be


    resolved
    To evaluate the nursing care and level of satisfaction among
    patients

    DISADVANTAGES OF NURSING
    ROUNDS/VISITS
    The confidentiality of the patient is hampered

    Distractions are present in the ward


    An unprepared nursing round has little teaching learning
    value

    It is not effective if the group is large


    It may evoke undue anxiety in the patient when his/her case in
    discussed.

    NURSING MANUALS
    It is the compilation of all the rules or guidelines

    concerning the procedures or management of identified


    problems which available for reference. The contents of

    the manuals, particularly in relation to the specific


    procedures are more acceptable if compiled following a

    group discussion.

    ADVANTAGES
    They
    specify
    the purpose for
    which
    the
    procedure is to
    be used, the
    equipment
    needed,
    the
    sequence
    of
    steps in the
    procedure and
    the precautions
    to be observed.

    The standards
    of performance
    are ensured

    Helps in the
    provision
    of
    safe
    and
    effective care
    with available
    resources and
    personnel

    DISADVANTAGES

    If the manuals are not revised periodically,


    faulty and old practices may continue.

    NURSING PROTOCOLS
    Protocols are written instructions for caregivers to follow when individuals

    have specific or frequent problems from a health concern that usually has a
    predictable outcome. Protocols give guidance to caregivers on signs and symptoms to
    looks for, when and how to intervene and who to notify.
    Protocols are sometimes confused with procedures. Procedures are task oriented. They

    provide step-by-step instructions on how to do a task. For example: how to administer


    a gastrostomy feeding or how to empty a Foley catheter bag.
    Standing orders are specific instruction regarding treatment for condition that nurses

    and other health workers may encounter in home, school and industries where a doctor
    is not readily available. The standing order are intended to provide treatment only in
    emergencies and temporarily in the absence of a doctor, they should be limited.

    PURPOSE
    To promote health services in community
    To provide temporary treatment in the
    absence of a doctor
    To deliver
    community

    care

    at

    home,

    school,

    To meet emergency situation in rural area

    TYPES OF STANDING ORDER


    1.

    Institutional standing orders


    They are kept keeping in view the available resources, staff position and the objectives of a
    medical institution or hospital. E.g. Standing orders of primary health centers can be different from
    those of district hospitals.

    1.

    Specific standing order

    These orders are meant for trained medical personnel, mainly the nurses. Technical knowledge
    and specific skills are required to implement these orders. E.g. giving care at home, injections,
    oxygen therapy etc.

    1.

    General standing orders


    Owing to a large population, vast geographical area and the shortage of resources, some standing
    orders are used to propagate health care messages to the masses. E.g. preventive measures against
    AIDS etc.

    ADVANTAGES OF STANDING ORDERS


    They help to strengthen the primary services in the

    community
    They help to decentralize the health responsibilities
    They provide a feeling of confidence and responsibility in

    the nursing staff and other health workers


    They enhances the quality and activity of health services

    Community standing orders provides timely treatment

    during emergencies

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