Method of Recording and Reporting Information Essay Discussion Paper
Question
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1. Provide details of both the recording and reporting requirements when undertaking a comprehensive clinical handover. |
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| Recording Requirements |
Reporting Requirements |
Step 1/3
Answer:- Record- It is a written communication that permanently documentation information related to client health care management.
Definition – Record is the memory of internal & external transaction of an organization.
Characteristics –
- Accuracy • Consciousness
- Thoughtful • Confidence
Purpose- • Communication • Aids of diagnosis • Educational • Documentation • Research
Uses of record –
- Organization of work • Help nurse to evaluate the care & the teaching.
- prevent duplicate services.
Types-
– patient clinical record – individual record – wards record
– administration record& educational record.
Step 2/3
Report- A report is a system of communication aim at transferring essential information necessary for sale & holistic patient care.
Purpose-
- To communicate progress of the patient’s health status to all nurses.
- To prepare staff members for their days work.
Types –
There are two types of report – oral report – written reports.
Written reports are different types – census reports
– mistake or accident reports
– interdepartmental reports
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Step 3/3
Types of record used in community health nursing
– cumulative reports or continuing reports.
– Family record.
Role of nurse manager in record keeping
– The nurse manager is accountable for the loss of any record – The nurse manager protects the record f
rom any kind of damage & safe guard the same.
Explanation:
The method of recording and reporting information- relevant to client care have develops a response to standards of practice, legal and regulatory standards, institutional standards and policies and society’ norms, oral communication about a client’s status is called reporting.
Documentation is any printed or written record of activities in health care it should include the following –
- changes in the clients condition.
- The administration of tests ,treatments, procedures done client education with the result of, or client responses to them.
- The client response to an intervention.
- The evaluation of expected outcome.
- complaints from client or family.
Final answer
The final answer is given in all the steps with brief discussion
Method of Recording and Reporting Information Essay Discussion Paper