Computer technology has been used in nursing documentation since the 1960s. Accurate documentation in medical records is critical for proper patient treatment and recovery. Records provide a permanent record of a patient's care and treatment, and support continuity of care between providers. Computers now play a vital role in hospitals by facilitating electronic patient record systems, which collect, store, and make clinical information easily accessible to support efficient patient care and treatment.
1. USE OF COMPUTER, PATIENT
RECORD SYSTEM, NURSING
RECORDS AND REPORTS
Presented by:
Ms. Prachi Garg
M.Sc. Nursing 2nd year
2. ■ Nightingale described the need for nurses to record "the proper use of fresh air, light,
warmth, cleanliness, the proper selection, and administration of diet." In Nightingale's time,
documentation was a way to communicate the implementation of doctors' orders and not a
means to observe or assess the patient's status. The use of computer technology in nursing
documentation has been reported since the 1960s.
■ Accurate documentation of patient symptoms and observations is critical to proper
treatment and recovery. Entries written in a patient's medical record are legal and are
permanent documents. The patient may receive improper or potentially harmful care in case
of a poor or wrong entry into a medical record.
INTRODUCTION
3. Definition of Computer
■ Computer is a device employed to compute or calculate.
■ It is an electronic device that receives input, stores it, operates
it according to a set of instructions, and gives the user the
appropriate output.
■ Computers can quickly and efficiently store, manipulate, and
retrieve massive amounts of data. Information stored in the
computers transmits links from one end to another end through
telecommunication.
4. Computer System
1. Hardware: this we can touch
and sees a part of the computer
(e.g. keyboard, mouse, etc.).
2. Software: The software of an
essential part of a computer
system and cannot be touched.
The software involves all the
programming that makes the
computer run, controlling all that
the computer does.
5. Computer Applications
■ 1.Information
application: Television,
virtual reality, and
multimedia applications
such as 3-D graphics,
robotics.
■ 2. Telecommunication
applications:
Videoconferencing,
electronic fund transfers
(EFTs), bulletin board
system (BBS), facsimile
transmission (FAX),
medicine, publication, and
accounting applications of
telecommunication.
6. Purposes of Using Computers
Administrative
purposes
Clinical
purposes
In community
and home health
nursing practice
Computers in
nursing research
Computers in
nursing
education
7. Advantages of Computers in Nursing
Improve and facilitate access to information
Reduce the redundancy of data entry
Decrease the time needed for nursing documentation
Increase the time of nursing care of patients
Facilitate data collection for research
Improve communication and reduce the risk of error
Work for decision-making
8. TELECOMMUNICATIONS
■ Telecommunication is a means of one- or two-way
communication to transmit messages. The examples of the
combination of IT are the telephone, computer, processor,
printer, etc. It saves time and money and secures data and
messages
11. Definitions of Documentation
■ Webster's dictionary defines "documents" as something written, furnishing evidence or
information and "documentation" as anything written or printed, which rely on as a
record of proof for authorized persons.
■Documentation is a system of recording either handwritten or electronically generated
information regarding the care or service provided to a patient. Health records may be
paper or electronic documents, such as electronic medical records (EMRs), faxes, e-
mails, audio or videotapes, etc.
■"Nursing documentation" is a process of making an entry of data on a record regarding
patients' care and service provided to the client.
12. PURPOSES OF DOCUMENTATION
To facilitate communication
To facilitate coordination of care
To promote continuity of care
To promote quality nursing care
To achieve professional and legal standards
Accountability
Security
Providing quality improvement
Facilitating evidence- based practice
14. Tools for Documentation
Initial nursing assessment
•Kardex and patient care summary
•Plan of nursing care
•Critical/collaborative pathways
•Progress notes
•Flow sheets
•Acuity charting forms
•Discharge/ transfer summary
•Home healthcare documentation
•Long-term care documentation.
16. Definition
■ Records are handwritten or computer based used for
specific purposes in any form. The recording, charting,
or documenting is a process of making an entry on a
client's record. A clinical record or client record is a
formal, legal document that provides evidence of a
client's care
17. Types of Records:
It is the entry of events
in a sequence form. It
includes all activities
related to the
collection and
utilization of clinical
information.
Hospital
record:
A medical record is a
clinical and scientific
record regarding
patient care. It is an
administrative and
legal document. It
provides detailed
information about
patient health history,
diagnosis, treatment,
and care written in a
sequential manner.
Medical record:
A nursing record
system is the record of
nursing care planned
and given to individual
patients by nurses. It
contains patient health
history, nursing
assessment, nursing
diagnosis, nursing care
plans, evaluation of
care, and progress of
patients.
Nursing record:
18. Objectives of Records
1. To review patient care, make clinical decisions, and prepare
treatment plans
2. To provide a legally acceptable record
3. To provide a source of information for health managers
4. It enables for hospital auditing
5. To carry out the things in the right possible manner.
6. It is useful for statistical, teaching, diagnostic, and legal
purposes.
19. Purposes of Medical Records
1. To patients
• To improve patient care
• To serve to document the clinical
history
• To aid in avoiding omission or
repetition
• To assist in the continuity of care
• To provide evidence in medicolegal
cases
• To supply the necessary information
to institutes and employees.
2. To health organization/ hospital
• To record all activities of the
healthcare providers
• To furnish proof of kind and quality
care
• To protect hospital in legal staff
• To evaluate the proficiency of staff
• To help in future program planning.
20. Functions of Records
To help in improving the responsibility and accountability of
healthcare providers
To depict decision-making related to patient care
To reflect the level of healthcare services and clinical judgments
and decisions
To provide a source of patient care and communications
To make the continuity of care more accessible and provide
evidence of services
To promote better discussion and coordination among team
members
To aid in identifying risks, and early detection of complications
To facilitate audit, research, allocation of resources, and
performance planning
To address complaints or legal processes.
21. Principles of Good Record Keeping
1. Handwriting should be legible
2. All recorded entries should be signed. Put the date and time on all documents
3. Records should be accurate and in such a way that the meaning is clear
4. Records should be readable
5. Records should be factual
6. Use professional judgment to record
7. Include only pertinent information
8. Do not alter or destroy any records without being authorized
9. Do not falsify records
10. Maintain confidentiality of the documents, follow rules governing confidentiality in respect of the supply, and use data for secondary purposes
11. Follow organizational policy and guidelines when using records for research purposes
12. Do not disclose the information and should not leave any documents, either on paper or on computer screens
13. Know how to use available information systems and tools
14. Ensure the proper use of the system, particularly about confidentiality
15. Assess the standard of record keeping and communications.
22. General Guidelines for Recording
Date and time Timing Legibility Permanency Correct spelling
Signature Accuracy
Use specific
descriptions
Do not erase or
use corrective
fluid
Sequence
Appropriatenes Completeness Conciseness
Standard
terminology
Legal cautious
23. Steps for Designing the Record
1. Constitute a committee. The members should be the head of
the department, hospital administrator, nursing head, supervisor,
and nursing staff of the operational level.
2. Call for repeated meetings to seek suggestions and prepare a
rough draft of record.
3. Test for its validity and also check the feasibility and utility by
conducting a pilot.
4. Periodically evaluate the record.
25. Definitions
■ The report is oral, written, or computer-based
communication intended to convey information to
others. These can be formal or informal.
■ Reporting is the process of informing the other staff
about the patients and of other events.
26. Objectives Of Reports
It presents the factual information to the management and thereby serves as a means
of communication.
It provides valuable clinical information of patients that can be used for future
reference
It provides necessary information to the department, clients and general public at
large
It is useful in measuring the performance of an employee
It makes valuable and constructive suggestions to management
27. TYPES OF
REPORTING
Change-Of-Shift Report Written report
Verbal report
Bedside report
Telephone report
Telephone orders
Transfer report
Incident reports or occurrence reports
Conferring
Intradivisional Report Among nursing staff
Between nursing sisters and staff nurses
Between nursing sister and matron
Between nursing sisters and doctors
Intradepartmental
Report
28. Change-Of-Shift Report
■It is a report by the nurses on one shift to nurses of the next shift change. It
provides continuity of care of the patient so the nurses by providing a quick
description of patient health status and details of care. The points that should
be kept in mind while reporting:
The information should be accurate, factual, organized.
Avoid negativism and subjectivity while reporting.
Use a written or printed guide to prompt thoroughness and
organization.
Be specific and avoid vague terms.
Describe the presence of all invasive treatments.
Focus on abnormal findings and variations from routine or the norm.
29. Intradepartmental Report
■It is the communication between two departments. The reports
are sent from one department to another or vice versa. For
example, in the hospital, the head of the nursing department sends
patients' report and the staff report to the medical superintendent.
Such reports include report book indicating reports of patients,
VIP and acute patients, any event or disaster mishappening,
accidents, complaints, staff performance reports, etc.
30.
31. Computers play a vital role in the day-to-day operations of hospitals. From
maintaining patient records to scheduling appointments, computers help hospital
staff work more efficiently and effectively. Patient record system is a type of
clinical information system, which is dedicated to collecting, storing, manipulating,
and making available clinical information important to the delivery of patient care.
A record is a written communication that permanently documents information
relevant to a patient's health care management. It is a continuing account of the
patient's health care needs
