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Nursing Documentation - Nursing: Reporting | 11th Nursing : Chapter 13 : Documentation

Chapter: 11th Nursing : Chapter 13 : Documentation

Nursing: Reporting

Reports may be oral or written form of documentation


Reports may be oral or written form of documentation


Types of reports.

·           Change of shift reports

·           Telephone reports

·           Family member reports

·           Incident reports

·           Legal reports.

. . . Chan e of Shift        eports

·           A change of shift reports is given by a primary nurse to the nurse who assumes responsibility for continuing care of the patient. The change of shift report might be given in written form or orally.

·           It   provides   basic   identifying information such as patient condition, current  appraisal  of  each  patients’ health status, current order by the physician,  changes  of  medication, intravenous fluids, diet, activity level.

·           Summary of each newly admitted patient.

·           Report on patients who have been transferred or discharged.

. . . elephone eports

·           Telephones and telemedicine equipment can link healthcare professionals immediately and enable nurses to receive and give critical information about patients in a timely fashion.

·           Report the patients’ current vital signs and clinical manifestation investigation etc.

. . . Family Mem er eports

·           Nurses play a crucial role in keeping the patient family and updated about the patients condition nurses should clarify their doubts and record their patient condition.

. . . Incident eports

·           It is a tool used by heath agencies to document the occurrence of anything out of the ordinary that results in harm to a patient, employee or visitor these reports are used for quality improvement.

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