It is an oral, written or computer based communication intended to convey information to others.
Eg: Reporting the patient's condition at the end of the hospital work shift.
· Essential tool for communication
· Indicates efficiency of the health care team.
· Avoid duplication of work
· Help the relieving person to plan the future care
· Quality patient care
Types of reports:
1. Change- of- shift reports
· It occurs 2-3 times in a day
· End of each shift nurse report the clients condition to other nurse working on next shift
· It provides continuity of care.
· It can be given orally, by audiotape or during rounds at client's bed side.
2. Telephone reports:
· It is the information given through telephone.
· It should be permanently documented in written forms if significant if significant changes in clients condition have occurred
· The person involved should ensure that the information is clear, accurate.
· Should document when the call was made, who made it, who was called to whom the information was given and what information was received
3. Transfer reports:
· It is given when the patient is transferred from one ward to other.
Eg: when a client transferred from ICU to general ward.
· It involves the communication about the client from one nurse on sending unit to the nurse on the receiving unit
4. Incident reports:
· An incident is any event not consistent with the routine operation of health care unit or routine care of the client. It will be filed as an incident report.
Eg:- client falls, needle stick injury.
· The report should be concise, accurate, reporting exactly what the nurse observes and administers the way of care.
· It is an integral part of quality improvement program .it helps to prevent the reoccurrence.
· Report among the members of nursing team.
· Report among the head nurse and her assistant.
· Report between head nurse and nursing superintendent
· Report to physician
Minimizing legal liability through effective record keeping:
While writing a record the nurse should keep in mind all the principles of record writing. It should not be merely routine or superficial the nurse must understand the legal implication of documentation.
CARE OF RECORDS:
· Kept under safe custody of the nurse in each department.
No individual sheet is separated
· Strangers not permitted to read record
· Handle carefully
· Not sent out of hospital without permission
· Maintain confidentiality of the records