Records and Reports
By
D/ Ahlam EL-Shaer
Lecture of Nursing Administration
Mansoura University- Faculty of Nursing
Outlines
of records and reports
 -Importance of records and reports
 -Kinds of Records
 -Records used in nursing unit
 -Records used in nursing office:
 -Kinds of reports
 -Oral Reports
 -Written reports
 -Guideline for written report

-Definitions
Records
Are administrative tools used to classify
and
prevent duplication of the
information.
Reports
Report is a document form which
include; conclusions or findings based on
facts, or recommendations concerning
the patient.
Importance of records and reports



Provide a way of communication among
the health care providers
Used as documentary evidence of the
course of the patient illness and treatment
during hospitalization.
Serve as a basis for analysis, study and
evaluation of the quality of care rendered
to patient.




Provide clinical data for research and
education.
Provide continuity of patient care on
subsequent admissions of the patients.
Serve as a basis for planning individual
patient care.
Assist in protecting the legal interests of
the client, health organization, and health
care providers.
Kinds of Records
(A) Records used in
nursing unit
1- Patient record
2- Assignment record
3- Time record
4- Census record
5- Inventories record
6- Narcotics and Medication
record
(b) Records used in
nursing office
1- Master record
2- Attendance record
3- Personnel record
 Employment record
 Evaluation record
Kinds of reports
It can be :-
(a) Oral report
(b) Written report.
(a) Oral Report
Are given when information is needed to
be reported immediately not for
permanency, e.g. oral reports given by
head nurse to all personnel, reports
about patient condition and needs.
(b) Written reports
It includes :
1- Day, evening and night report.
2- Incident report.
3- Report of complain.
4- Report including negligence.
5- Reports for requisition.
Guideline for written report:
1.
2.
3.
4.
5.
Have the patient’s name and hospital
number.
Initiate each entry with the data and time.
Chart after providing care, not before.
Chart as soon as possible.
Chart only your own observation, care, and
teaching.
6- Be objective in charting.
7- Use permanent black ink pens.
8- Be specific, accurate, and complete.
9- Use concise phrase, begin each phrase
with capital letter and each new topic on a
separate line.
10- Use only approved abbreviations.
11- Use medical terminology.
12- Follow rules of grammar.
13- Fill all spaces.
14- Correct errors in documentation.
15- Don’t erase the error.
16- Draw a single line through any
erroneous information.
17- Sign each block of charting.