NU 401 :

Department

Faculty of Nursing

Academic Program

Bachelor in Science in Nursing

Type

Compulsory

Credits

02

Prerequisite

NU 400

Overview

This course provides an understanding of the importance of records and reports in the practice of nursing. It focuses on the enhancement of skills in record keeping, writing reports, care plans, cover letters, scientific papers and other forms of documentation commonly done by nurses in their practice of nursing.

Intended learning outcomes

Knowledge and understanding:

1- Recognizes the importance of records, reports and documentation in the practice of nursing.

2- Develops deeper understanding of the necessity of keeping accurate recording and reporting.

3- Recognizes the nurse's role in keeping an updated, accurate and organized records and

reports in the care of patients.

4- Develops a broader knowledge base and understanding of the legal, professional and personal accountability in recording, reporting and documentation.

Mental skills:

1- Differentiate records, reports and documents.

2- Explain the purposes of records and reports.

3- Demonstrates critical thinking skills in writing reports, documentation and keeping accurate and up to date clinical records during patient care.

4- Differentiate the different methods of recording.

5- Shows a deeper understanding of the legal, professional responsibility and personal accountability in record keeping, reporting and documentation in patient care.

Scientific and professional skills:

1- Applies principles of maintaining records and reports.

2- Displays skills in accomplishing common ward records and reports.

3- Utilizes the nursing process in designing nursing care plans for clients in need of critical care.

4- Applies the principles and characteristics of good reporting and recording in the practice of nursing in different settings such as clinics, hospitals or community.

General skills

1- Displays interest and motivation in learning new skills in record keeping.

2- Shows initiative and personal responsibility in maintaining and professional growth.

3- Displays communication and human relation skills in dealing with clients, client's family,

Health care team, group mates, etc.,

4- Applies guidelines of writing good report not only in the practice of nursing.

Teaching and learning methods

· Lecture /discussion .

· Group Dynamics

Methods of assessments

• Midterm exam 33%.

• Final exam 52%.

• Assignments/HWs/Quizzes 15%

Course Outline

1. Definition of Records, reports, documents 2. Comparison of records, reports, documents 3. Characteristics of good recording and reporting a. Accuracy b. Conciseness c. Thoroughness d. Up to date e. Organization f. Confidentiality g. Objectivity

4. Purposes of Recording and reporting: 1. Decision Making. 2. Communication 3. Reimbursement. 4. Legal accountability. 5. Education. 6. Assessment. 7. Planning. 8. Research 9. Audit. 10. Historical document. 11. Quality assurance. 12. Vital statistics. 13. Health service planning 14. Diagnostic and the therapeutic orders. 15. Accrediting and licensing

5. Principles of maintaining records 6. Ward records 1. Patient’s Clinical Record 2. Doctor Order Sheet 3. Reports of Laboratory Examination 4. Diet sheet 5. Consent Form for Operations and Anesthesia 6. Intake and Output Chart 7. Reports of Physiotherapy, Occupational Therapy 8. Kardexes 9. Instruction Book 10. Admission and Discharge record 11. Census Record 12. Call book 13. Complaint Book 14. Movement register 15. Indent Book 16. Drug’s Maintenance Register 17. Record of Death

7. Methods of recording: 1. Narrative charting 2. Source - Oriented Charting 3. Problem-oriented charting 4. PIE charting 5. Focus charting 6. Charting by exception 7. Graphic Sheets and Flow Sheets 8. Nursing Care Plan

8. Principles of Record Writing 9. Types of reports: 10. Benefits of a good report 11. Types of reports used in hospital setting: 1. Change - of - shift reports 2. Transfer report 3. Incident reports 4. Census report 5. Birth and death report 6. Anecdotal report 12. Incident report and its purposes 13. Incidents that require reporting 14. Tips for writing incident reports 15. Guidelines for a good report

(AR 101)
(ST 101)
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(BC 211)
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(NU321-ICU)
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