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Course Outline |
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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
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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 Historical document. 11.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
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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
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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
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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
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