ASSIGNMENT

ON
RECORDING AND REPORTING IN HOSPITAL
AND COLLEGE OF NURSING

Submitted to- Ms. Rajlaxmi

Tutor
Rufaida College of Nursing
Submitted by- Ms. Sneha Sehrawat
M. Sc. Nursing (OBG)
Rufaida College of Nursing
Subject-Nursing Management & Administration
INTRODUCTION

Professional Standards are necessarily required for nurses to document

timely and accurate reports of relevant observations, including conclusions
drawn from those observations. Documentation is any written or
electronically generated information about a client that describes the care or
service provided to that clientAll professional nurses need to be accountable
for the performance of their duties to the public. Since nursing has been
considered as profession, nurses need to record their work on completion.
Records are a practical and indispensable aid to the doctor, nurse and
paramedical personnel in giving the best possible service to the clients.
Report summarizes the services of the person or personnel and of the
agency.

The term documentation is used in this publication means any written or

electronically generated information about a client that describes the care or
service provided to that client. “Client” refers to individuals, families,
groups, populations or entire communities who require nursing expertise. It
allows nurses and other care providers to communicate about the care
provided. It promotes good nursing care and supports nurses to meet
professional and legal standards of Documentation.
• Nursing Documentation is that part of the clinical record written by
nurses and is the total written information concerning patient’s health
status, nursing needs, nursing care, and response to nursing care. Key
components of nursing documentation includes assessments, nursing
diagnoses, planned care, nursing interventions, patient teaching, patient
out come, and interdisciplinary communication
• Nursing Documentation comprises of all written and/or computerized
recordings of relevant data made by nurses to document care given or to
communicate information relevant to the care of a particular
client/patient. Other supporting documentation includes:
 Policies/Procedures/Protocols
 Rosters
 Incident Reports
 Performance Appraisals/Assessments
 Personnel Files
 Computer Generated Data
 Dependency Studies
 Research Data
 Documents required for health finding purposes
• Temporary media, such as audio taped or video taped handovers, should
not be considered as a substitute for full and proper documentation in
client/patient records
Purposes of Documentations:
• Professional accountability
• Professional responsibility
• Quality assurance
• Patient client’s teaching
• Education
• Research
• Reimbursement
• Prevention of missing something in care
• Prevention doubling or duplication in care
• Monitoring
• Communicate information accurately, effectively and in a timely fashion
• Financial billing
• Assessment
• Auditing
• Legal record
• Legal and practice standards and protection
• Who else depends on the information in the record?
o Medical records and Coding department
o Billing and finance
o Internal and External quality monitoring
o Insurance companies and Attorneys
o Secondary users of varying sophistication.
 Legal and ethical issues
 What may be obvious at the time needs to be explicitly stated
for later reference (hours, days, years later)
 Need to reflect complexity of medical services provided
 Language does matter - Accuracy and specificity are essential

Reason for Documentation:

• To facilitate communication: Through documentation, nurses
communicate to other nurses and care providers their assessments about
the status of clients, and nursing interventions that are carried out the
results. Documentation of this information increases the likelihood that
the client will receive consistent and informed care or service. Accurate
documentation decreases the potential for miscommunication and errors.
However documentation is most often done by nurses and care providers,
there are situations where client(s) and family (ies) may document
observations and / or care provided in order to communicate with
members of the health care team
• To promote good Nursing care: Documentation encourages nurses to
assess client progress and determine which interventions are effective
and ineffective, and identify and document changes to the plan of care as
needed. Documentation can be a valuable source of data for making
decisions about finding and resource management as well as facilitating
nursing research, all of which have the potential to improve the quality of
nursing practice and client care. Individual nurses can use outcome
information or information from a critical incident to reflect on their
practice and to make necessary changes based on evidence
• To meet professional and legal standards: Documentation is a valuable
method for demonstrating that, within the nurse-client relationship, the
nurse has applied nursing knowledge, skills and judgment according to
professional standards. The nurse’s documentation may be used as
evidence in legal proceedings such as lawsuits, coroners’ inquests, and
disciplinary hearings through professional regulatory bodies. In a court of
law, the client’s health record serves as the legal record of the care or
service provided. Nursing care and the documentation of that care will be
 measured according to the standard of a reasonable and prudent nurse
with similar education and experience in a similar situation.
RECORDS

A record is a permanent written communication that documents information

relevant to a client’s health care management.

A record is a clinical, scientific, administrative and legal document relating

to the nursing care given to the individual family or community.

PURPOSES OF RECORDS

 Supply data that are essential for program planning and evaluation.
 Provide the practitioner with data required for application of
professional services for the improvement of family’s health
 Tools of communication between health workers, the family and other
development personnel.
 Effective health records show the health problem in the family and
other factors that affect health.
 Indicates plans for future.
 Helps in the research for improvement in nursing care.
 It provides baseline data to estimate the long - term changes related to
services.

ADMINISTRATIVE PURPOSE OF CLINICAL RECORDS

  Legal documents – poisoning, assault, rape, LAMA, burn etc.
 Research or statistics : rates
 Audit and nursing audit
 Quality of care
 Continuity of care
 Informative purposes
 Teaching purpose of students
 Diagnostic purposes – test reports

PRINCIPLES OF RECORD WRITING

 Nurses should develop their own method of expression and form in

record writing.
 Written clearly, appropriately and adequately.
 Contain facts based on observation, conversation, and action.
 Select relevant facts and the recording should be neat, complete and
uniform.
 Valuable legal documents and so it should be handled carefully, and
accounted for.
 Records should be written immediately after an interview.
 Records are confidential documents.
 Accurately dated, timed and signed.
 Not include abbreviations, jargon, meaningless phrases.
REPORTS

Reports are oral or written exchanges of information shared between

caregivers or workers in a number of ways.

A report is the summary of the services of person or personnel and of the

agency.

IMPORTANCE OF REPORTS

- Good reports save duplication of effort and eliminate the need for
investigation to learn the facts in a situation.
- Full reports often save embarrassment due to ignorance of situation.
- Patients receive better care when reports are through and give all
pertinent data.
- Complete reports give a sense of security which comes from knowing
all factors in the situation.
- It helps in efficient management of the ward.

PURPOSES OF REPORTS

 To show the kind and quantity of services rendered over to a specific

period.
 To show the progress in reaching goals.
 As an aid in studying health conditions.
 As an aid in planning.
  To interpret the services to the public and to other interested agencies.

CRITERIA FOR A GOOD REPORT

 Reports should be made promptly if they are to serve their purpose

well.
 A good report is clear, complete concise.
 If it is written all pertinent, identifying data are include – the date and
time, the people concerned, the situation, the signature of the person
making the report.
 It is clearly stated and well organized for easy understanding.
 No extraneous material is included.
 Good oral reports are clearly expressed and presented in an interesting
manner. Important points are emphasized.

TYPES OF REPORTS

Oral Reports – Oral reports are given when the information is for
immediate use and not for permanency. E.g. It is made by the nurse who is
assigned to patient care, to another nurse who is planning to relieve her.

Written Reports – Reports are to be written when the information to be

used by several personnel, which is more or less of permanent value, e.g.
day and night reports, census, interdepartmental reports, needed according to
situation, events and condition.
ANECDOTAL RECORD

An anecdote is a brief account of some interesting event or incident.

Significant incidents or specific observable behaviors can be recorded by
teachers in anecdotal records. These records provide cumulative information
about student's development in the learning objectives of the language arts
as well as their physical and social growth and development. By
systematically collecting and analyzing anecdotal comments, teachers can
evaluate student’s progress and abilities to use language and then plan
appropriate instruction.

Meaning

Informal device used by the teacher to record behavior of students as

observed by him from time to time.
It provides a lasting record of behavior which may be useful later in
contributing to a judgment about a student.

Characteristics of anecdotal records

Anecdotal records must possess certain characteristics as given below:

 They should contain a factual description of what happened, when it

happened, and under what circumstances the behavior occurred.
 The interpretations and recommended action should be noted
separately from the description.
 Each anecdotal record should contain a record of a single incident.
 The incident recorded should be that is considered to be significant to
the student’s growth and development.
 Simple reports of behavior
 Result of direct observation
 Accurate and specific
 Gives context of child’s behavior.
 Records typical or unusual behaviors
Purpose

 To furnish the multiplicity of evidence needed for good cumulative

record.
 To substitute for vague generalizations about students specific exact
description of behavior.
 To stimulate teachers to look for information i.e. pertinent in helping
each student realize good self – adjustment.
 To understand individual’s basic personality pattern and his reactions
in different situations.
 The teacher is able to understand her pupil in a realistic manner.
 It provides an opportunity for healthy pupil – teacher relationship.
 It can be maintained in the areas of behavior that cannot be evaluated
by other systematic method.
 Helps the students to improve their behavior, as it is a direct feedback
of an entire observed incident, the student can analyze his behavior
better.
 Can be used by students for self appraisal and peers assessment.
Items in anecdotal records

 To relate the incident correctly for drawing inferences the following

items to be incorporated.
 The first part of an anecdotal record should be factual, simple and
clear.
 Name of the subjects
 Unit/ward/department
 Date and time
 Brief report of what happened.
 The second part of an anecdotal record may include additional
comments, analysis ad conclusions based on interpretations and
judgments.

Advantages of anecdotal records

 Supplements and validates of other structured instruments.

 Provision of insight into total behavioral incidents.
 Needs no special training.
 Use of formative feedback.
 Economical and easy to develop.
 Open ended and can catch unexpected events.
 Can select behaviors or events of interest and ignore others, or can
sample a wide range of behaviors.
Disadvantages of anecdotal records

 If carelessly recorded, the purpose will not be fulfilled.

 Only records events of interest to the person doing the observation.
 Quality of the record depends on the memory of the person doing the
observation.
 Incidents can be taken out of context.
 Subjectivity
 Lack of standardization
 Difficulty in scoring
 Time consuming
 May miss out on recording specific types of behavior.
 Limited application
ANECDOTAL RECORD
Student: Age:

Observer: Date:

Setting:

Objective:

Observational details

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Analysis

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HANDING OVER AND TAKING OVER REPORTS

Overall objective

a) To ensure that patient care continues seamlessly and safely, providing

the oncoming
nurses with pertinent information to begin work immediately.
b) To maintain the ongoing confidentiality of patient records.

Definition

The nursing change of shift report or handover is a communication that

occurs between two shifts of nurses whereby the specific purpose is to
communicate information about patients under the care of nurses (Lamond,
2000).
Target users

All nursing and midwifery staff involved in the transfer of patient

information from one member of staff to another.

Nursing handover for adult patients guidelines

1. The shift report may occur in some areas up to three times a day. It
may vary in length from a ‘full report’ lasting between 30 minutes up
to an hour or longer to a ‘head line report’ which may give a quick
overall patient update following a particular busy part of the day.
2. Handover should not just be directed towards the nurse in charge. All
nurses coming on to a shift need a handover.
3. The start of the handover is also the best opportunity for the nurse in
charge to formally hand over the controlled drug keys (if appropriate)
to the oncoming person in charge of the shift.
4. A safety briefing is undertaken at the beginning of a shift handover.
This should not extend the time of handover, should last only 2-3
minutes and the focus should be the specific patient safety issues for
that clinical area on that shift. This information should be carried
forward to the next shift and should simply highlight safety as a main
priority.
5. The Situation, Background, Assessment and Recommendation
(SBAR) model can be used by any health professional to
communicate clinical information about a patient’s condition.
  Use a structured approach to enable all staff to focus on
handing over what is relevant, avoiding overload and passing
on irrelevant information.
Principles of Documentation:
The following principles should be applied.
• The documentation is directed primarily to serving the interests of the
client
 The primary purpose of client patient health records should be to
facilitate the provision of care
• Frequency of documentation of documentation is ultimately a
professional judgment. Nurses should ensure that all entries are:
 Chronological and timely
 Comply with any policy of the health care agency/organization
 Fulfill legal requirements
 Adhere to the principles listed in these standards
 The frequency of entries, made in a client’s / patient’s health record, is
dependent on several factors. These include, but are not restricted to:
o The physical / mental condition of the client/patient
o The method of documentation used by the health care
facility/organization
o Any other obligations (legal or otherwise) that the health record
must fulfill
 In circumstances where a client / patient is in unstable health, it is
necessary to document more frequently than in circumstances where
the client/ patient may be in more stable health, such as in long-term
care
• The documentation records events chronologically and in a timely
manner; Entries in client/ patient health records should be in
chronological sequence, with time, date, and signature and staff
designation
Entries must be made as close as possible, to the care or treatment
provided
Waiting until the end of a shift to “write the report” should be avoided as
such practices enhance the likelihood of errors, omissions or
“misremembering”
It is permissible to document at a later time if pertinent data is omitted or
not included at the time an event occurs. A late entry is preferable to
no entry at all
To avoid confusion when documenting at a later time, include both the
time and date that the entry is made, and the time and date that the
entry refers to- It is also permissible to add a brief comment
explaining why the documentation has occurred at the later time
If the record is to be amended in this way, it should always be undertaken
by the nurse who provided the care
Spaces should NOT be left in a client/patient’s record for documentation
to be completed at a later time

• The documentation is concise, legible, accurate, and contemporaneous;

all entries should be brief, complete, and unambiguous. Verbosity leads
to difficulties in interpretation, and may delay access to vital information.
All entries must be made in ink, and any blank areas in a report should be
ruled out. All entries should include the date, and the time that the
documentation occurs.
  A person making any documentation in a client/ patient record must
be able to be identified; therefore all entries in the health record,
including signatures, should be legible. Nurses should ensure that
their name and designation is printed clearly with their signature, to
aid identification
 The record should not consist of subjective expressions of opinion on
issues irrelevant to the management of the client! patient
 Recording errors should be promptly corrected by drawing one line
through the incorrect information
 The time, date and signature of the person altering the record should
then be entered. It is also advisable to record the reason and brief
description for alteration
 Under no circumstances should “white out” be used or an entry
obliterated by scribbling over it or tearing the entry out, as this greatly
diminish the credibility of the record -
• The documentation is in an approved format:
 Health care agencies/organizations should ensure that they have
written policies in regard to the format. A tick () cannot be considered
as an acceptable abbreviation, or as a substitute for time, initials or a
signature
 Health care agencies/organizations should ensure that they have
written policies outlining the requirements for registered nurses to
countersign entries made by other health care workers e.g. Students
and unregulated health care workers. Such policies promote clear
communication and minimize the risk of incorrect interpretation of
data
• The documentation uses approved abbreviations: Abbreviations in
nursing documentation should be kept to a minimum level
No abbreviation should be used unless it has a clear and unambiguous
meaning
Health Care agencies/organizations should ensure that a list or book, with
acceptable abbreviations and terminology for use in client/patient
health care records, is available

• The documentation contains only entries recorded by the individual

practitioner who provided the care:
 Nurses should not document on behalf of others
 All persons who provide care, make observations, should make an
entry in the client’s I patient’s health record
 The nurse, in accordance with the health care agency, should record
verbal orders given to them by another health care professional. This
ensures continuity and safety of client/patient care
• The documentation demonstrates that the nurse has fulfilled their duty of
care to the client
 All care, advice and any specific nursing management plans should be
documented clearly in the client’s / patient’s health record
 Duplication of information in health records should be avoided
 Refusal of treatment, advice or medication should be noted in the
health record
• Auditing and monitoring of documentation: Planning and patient
assessment rely heavily on accuracy and quality in all documentation.
Organizations are encouraged to regularly monitor and audit
 documentation within their organization. Such procedures could be
included within the annual quality plan of departments and units:
Qualitative review - evaluating the quality of documentation and
assessing adherence to clinical practice standards, regulations,
standards, interpretations and consistency within the documentation.
A qualitative review identifies strengths and weaknesses and provides
suggestions to correct future documentation discrepancies
Quantitative review — evaluating completeness, authenticity and timely
entry of the documentation. A simple assessment tool requiring a yes I
no responses or checklist could be used
• Documentation is a written plan for care which include:
Treatments and medications
Specifying frequency and dosage
Referrals and consultations
Patient or family education
Special instructions for follow-up

• Comprehensive, flexible and dynamic

• Reflect current standards
• Medical record should be complete and legible
• Each Patient I Client encounter should include:
 Date
 Reason for the encounter
 Appropriate history and physical examination
 Review of labs, x-ray and other ancillary
 Assessment
 Plan for care including discharge plan
Documentation may be accessible including past and present diagnoses to
the treating and br consulting physician and health care provider
Reasons and results of:
 x-rays
 lab test
 Other ancillary services
 Relevant health risk factors
Documentation of patient’s progress includes:
 Intervention
 Response to treatment or intervention
 Change in treatment
 Change in diagnosis
 Patient non-compliance
Documentation should support the intensity of the patient’s evaluation
and/or treatment including thought processes and complexity of medical
decision making.
HANDING OVER REPORT

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NURSES NOTES

Nurses notes are recognized as documentary evidence. Nurse’s notes are

viewed as a record of the nursing care provided to the client. The following
are the conditions in which the nurses notes are admissible:
 Nurses notes must be made contemporaneosly
 Nurses notes must be made by someone having personal knowledge
of the matter than being recorded.
 Nurses notes must be made by someone under a duty of care to make
the entry or record.

Purposes

 To promote good nursing care.

 Encourages nurses to access client progress and to determine which
interventions are effective, identify and document changes to the plan
of care as needed.
 Facilitating nursing research, all of which have the potential to
improve the nursing practice and client care.
DAY AND NIGHT REPORT (CHANGE OF SHIFT REPORT)

It is a report given to all nurses on the next shift. Its purpose is to provide
continuity of care for clients by providing a quick summary of client needs
and details of care to be given to the on-coming staff. The points that should
be kept in mind while reporting:

 The information should be accurate, factual and organized.

 Avoid negativism and subjectivity while reporting.
 Use written or printed guide to prompt thoroughness and organization.
 Be specific and avoid vague terms.
 Describe presence of all invasive treatments.
 Focus on abnormal findings and variations from routine or the norm.

Types of change-of-shift reports:

 Written report
 Verbal report
 Bedside report
DAY AND NIGHT REPORT
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OFFICIAL LETTER (Official Correspondence)

Correspondence is the return of communication between two persons;

agencies or institutions or departments. It can be personal or official.

It is any written or digital communication exchanged by two or more parties.

It may be in the form of letters, e-mails, text messages, post-cards etc.

Importance of official letters:

 It serves as a paper trail of events.
 It acts as a reference point for further communication.
 They create and maintain goodwill of employees and employers.
 It serves as evidences for legal purposes by keeping a record of all
facts.
GENERAL INFORMATION

 Documentation is the foundation of good nursing practice

 There are multiple types of charting methods utilized
 All methods are based on the nursing process.

- Assessment: observation for signs of actual or potential problems

- Planning: determining a plan of care targeting identified issues
- Implementation: the actions required for resolution of the problem
- Evaluation: reviewing the plan of care for effectiveness

 Several principles apply to all charting methods. "If it isn't charted, it's
not done".
 Timeliness is important: chart as care is provided, do not wait until the
end of shift to record the days work.
 Charts are legal documents and should be accurate, concise, and
complete.
 Never chart prior to actually performing care (i.e. don't chart
medications given until the patient actually takes them).
 Use straightforward language: provide accurate measures ("ate 90% of
dinner" not "ate well").
 Provide objective information; avoid subjective observations and
assumptions.
 Avoid use of personal comments or judgments.
 Refer to each institution's policies and procedures for specific
information.
 JCAHO has established a list of non-allowed medical abbreviations
which will be included in an institution's policies.
 Write "unit", not "U"
  Write "international unit", not "IU"
 Use "daily", not QD
 Use "every other day", not QOD
 Never write a zero after a decimal point
 Always write a zero before a decimal point
 Write "Morphine Sulfate", not MS
 Write" Magnesium Sulfate", not MSO4
 Write "Magnesium Sulfate", not MgSO4
 Use caution to not just repeat what was checked previously.

NURSES RESPONSIBILITY FOR RECORD KEEPING AND

REPORTING

 The patient has a right to inspect and copy the record after being
discharged.
 Failure to record significant patient information on the medical record
makes a nurse guilty of negligence.
 Medical record must be accurate to provide a sound basis for care
planning.
 Errors in nursing charting must be corrected promptly in a manner
that leaves no doubts about the facts.
 In reporting information about criminal acts obtained during patient
care, the nurse must reveal such information only to the police,
because it is considered a privileged communication.
 FACT – Information about client and their care must be functional. A
record should contain descriptive, objective information about what a
nurse sees, hears, feels and smells.
 ACCURACY – A client record must be reliable. Information must be
accurate so that health team members have confidence in it.
 COMPLETENESS – The information within a recorded entry or a
report should be complete, containing concise and thorough
information about a client care or any event or happening taking place
in the jurisdiction of manager.
 CURRENTNESS – Delays in recording or reporting can result in
serious omissions and untimely delays for medical care or action
legally, a late entry in a chart may be interpreted on negligence.
 ORGANIZATION – The nurse or nurse manager communicates
information in a logical format or order. Health team members
understand information better when it is taken in the order in which it
is occurred.
 CONFIDENTIALITY – Nurses are legally and ethically obligated to
keen information about client’s illnesses and treatments confidential.
NURSE’S NOTES
Name of the patient: Mr. Prashant Khatri Bed no. 08
Diagnosis: Pulmonary Tuberculosis
Age: 50 years Ward: Male Medicine Ward
Surgery performed: Not performed
Sex: Male Date of admission: 08/1/2018
Date of surgery: ---
IPD No. 947954

DA MEDICATION DIET TIM NURSING OBSERVATION, SIG

TE E INTERVENTION & REMARK N
06/1  Isoniazid 1 glass 08.00  Patient is lying on the bed.
2/20 (INH) (300 of milk am to
12 Greeted him. He responded
mg daily) with 2 4 pm
back verbally. Patient is well
 Rifampin slices of
(Rifadin bread oriented to time, place and
(600 mg person. He reported disturbed
daily) 1 glass
sleep last night because of
 Pyrazinami of
de (1 g orange breathing difficulty.
daily) juice at  Breakfast given to the patient.
 Ethambutol 11 am.  Medications are administered
(Myambuto
l) 1 gm Khichad to the patient according to the
daily i with orders.
 Tab. milk in
 Nebulisation given to the
Voveran the
lunch at patient.
5mg BD
 Tab. 12.30  A soft diet containing
Rantac 150 pm. khichadi was given to the
mg BD
client. Client had it nicely.

 Health education on the food

hygiene and handling of the
food in the house is given to
the patient and his wife.

06/1  Isoniazid 1 glass 08.00  The bed was unclean and

2/20 (INH) (300 of milk am to
12 mg daily) in the 4 pm untidy. Bed making procedure
 Rifampin breakfas
was performed and bed looks
(Rifadin t at 9
am. neat and tidy now.
(600 mg
daily) Plain  Vital signs were monitored
 Pyrazinami rice for the patient. Axillary body
de (1 g with
milk in temperature - 99°F. Pulse –
daily)
 Ethambutol the 78/min. Respiratory rate –
lunch at
(Myambuto 28/min.
12.15
l) 1 gm pm.  Medications were
daily
 Tab. 1 glass administered as per doctor’s
Voveran of order. The rights of
5mg BD orange
juice at medication administration
 Tab. 2 pm. were followed.
Rantac 150
mg BD  Explain about dietary
management to the patient.
 Knowledge given about
disease condition.
 Steam inhalation given to the
patient.
 Breathing exercises taught to
the patient with
demonstration..
 Uses of medication explained
to the patient and family
members.
 Explain the dietary
management and disease
condition to the patient and
family members.
DA MEDICATION DIE TIME NURSING OBSERVATION, SIG
TE T INTERVENTION & REMARK N
07/1  Isoniazid 1 08.00 am
2/20 (INH) (300 glas To  Vital signs were monitored
12 mg daily) s of for the patient. Axillary body
4 pm
 Rifampin mil
temperature – 98.8°F. Pulse –
(Rifadin k
(600 mg and 75/min. Respiratory rate –
daily) bisc 26/min.
 Pyrazinami uits  Medications were
de (1 g in
daily) the administered as per doctor’s
 Ethambutol brea order. The rights of
(Myambuto kfas medication administration
l) 1 gm t at
7 were followed.
daily
 Tab. am.  Oral hygiene given to the
Voveran patient.
5mg BD Plai
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 Tab.
Rantac 150 khic and extremities skin.
mg BD hdi
 Patient look anxious about the
with
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k in explanation given about the
the disease and treatment.
lunc
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12.1 patient.
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pm.
exercises and energy
conservation techniques were
taught to the client.
 Patient was provided with the
lunch and He had it nicely.
 Health education given to the
patient and family member.
DATE MEDICA DIET TI NURSING OBSERVATION, SIG
TION ME INTERVENTION & REMARK N
08/12/  Isonia 1 glass 08.0
2012 zid of milk  Vital signs were monitored for the
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am
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pm
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per doctor’s order. The rights of
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(600 given followed.
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 Oral hygiene given to the patient.
daily) patient
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namid ing, extremities skin.
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 Patient look anxious about the
g hapatti
daily) and disease and treatment so the
 Etham green explanation given about the
butol leafy
disease and treatment.
(Mya vegeta
ble.  Some deep breathing exercises
mbuto
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gm techniques were taught to the
daily
client.
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c 150
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BD
ENQUIRY REPORT

Enquiry report for the Oral enquiry and personal hearing conducted on
18.11.2002 at 10.00 A.M by the Enquiry Officer Dr.T.P.Kalaniti, Additional
Professor of Medicine, Government Mohan Kumaramangalam Medical
College, Salem on Thiru.P. Shanmuga sundaram, Male Nursing Assistant at
Government Mohan Kumaramangalam Medical College Hospital, Salem-1
at the venue of Professor of Medicine’s chamber, Government Mohan
Kumaramangalam Medical College Hospital, Salem-1 for the disciplinary
action initiated against him for serious allegations of corruption, indiscipline
and dereliction of duty.

Introduction:

I, Dr.T.P.Kalaniti, Additional Professor of Medicine, Government Mohan

Kumaramangalam Medical College, Salem had been appointed as the
Inquiry Officer to enquire into the charges framed against Thiru.P.
Shanmugasundaram, Male Nursing Assistant at Government Mohan
Kumaramangalam Medical College Hospital, Salem-1, vide
R.No.11057/E4/2002 dated 29.10.2002 of the Dean, Govt.Mohan
Kumaramangalam Medical college, Salem.1.

I conducted the oral Inquiry and personal hearing on the said Male Nursing
Assistant on 18.11.2002 at 10.00 A.M at the Professor of Medicine’s
chamber, Government Mohan Kumaramangalam Medical College Hospital,
Salem-1 and submit my enquiry report as detailed below –

Charges that were framed:-

Charge No. 1.

That Thiru.P. Shanmugasundaram, Male Nursing Assistant at Government

Mohan Kumaramangalam Medical College Hospital, Salem-1 was irregular
in his duties, failed to dress the wound and apply medicines in time to the
patients and thus he was negligent in his duties.

Charge No. 2.
That Thiru.P. Shanmugasundaram, Male Nursing Assistant at Government
Mohan Kumaramangalam Medical College Hospital, Salem-1 used to smoke
while on duty and even at the time of dressing the wound of patients, in spite
of their objections and thus he failed to follow the discipline and decorum of
a public servant.

Charge No. 3.

That Thiru.P. Shanmugasundaram, Male Nursing Assistant at Government

Mohan Kumaramangalam Medical College Hospital, Salem-1 had
demanded and accepted money from the patients to provide treatment to
them and thus he indulged in corrupt activities, which is unbecoming of a
Government servant.

Charges which were admitted or dropped or not pressed, if any:-

All the three charges were admitted.

Charges that were actually enquired into:-

All the three charges were enquired into.

Brief statement of the facts and documents which have been admitted:-

Thiru.P.Shanmugasundaram, M.N.A, Govt.Mohan Kumaramangalam

Medical College Hospital, Salem.1 was placed on duty in the ortho ward of
the hospital.

While he was posted for duty in the above ward, he did not attend the ward
duties in time. He also did not dress the wounds of the patients in time. He
used to attend the ward only at the fag end of the day and attend some of the
patients and leave others unattended

He was in the habit of smoking cigarettes, while attending his duties and
even at the time of dressing the wounds in spite of the objections of the
patients.
He used to demand money from the patients for dressing their wounds and to
take them to the operation theatre and accepted illegal gratifications.

Written complaint dated 22.08.2002 by the patients in the Ortho ward.

Preliminary enquiry report dated 26.08.2002, conducted as per R.No. Spl/

E4/2002 dated 24.08.2002 of the Dean, Govt.Mohan Kumaramangalam
Medical College hospital, Salem.1.

Charge Memo – R.No.11057/E4/2002 dated 24.09.2002 of the Dean,

Govt.Mohan Kumaramangalam Medical College Hospital, Salem.1.

Written statement of Defense of Thiru.P.Shanmugasundaram, M.N.A. dated

01.10.2002.

Brief statement of the case of the disciplinary authority in respect of the

charges inquired in to:-

Charge No. 1 states that Thiru.P. Shanmugasundaram, Male Nursing

Assistant at Government Mohan Kumaramangalam Medical College
Hospital, Salem-1 was irregular in his duties, failed to dress the wound and
apply medicines in time to the patients and thus he was negligent in his
duties.

Charge No. 2 states that Thiru.P. Shanmugasundaram, Male Nursing

Assistant at Government Mohan Kumaramangalam Medical College
Hospital, Salem-1 used to smoke while on duty and even at the time of
dressing the wound of patients, in spite of their objections and thus he failed
to follow the discipline and decorum of a public servant.

Charge No. 3 states that Thiru.P. Shanmugasundaram, Male Nursing

Assistant at Government Mohan Kumaramangalam Medical College
Hospital, Salem-1 had demanded and accepted money from the patients to
provide treatment to them and thus he indulged in corrupt activities, which is
unbecoming of a Government servant.

A wospital, Salem., Salem.1AAritten complaint dated 22.08.2002 was

received from the patients in the Orthopedics ward about
Thiru.P.Shanmugasundaram, M.N.A, Govt.Mohan Kumaramangalam
Medical College Hospital, Salem.1 who was placed on duty in the
Orthopedics ward of the hospital. While he was posted for duty in the above
ward, he did not attend the ward duties in time. He also did not dress the
wounds of the patients in time. He was in the habit of smoking cigarettes,
while attending his duties and even at the time of dressing the wounds in
spite of the objections of the patients. He used to attend the ward only at the
fag end of the day and attend some of the patients and leave others
unattended. He used to demand money from the patients for dressing their
wounds and to take them to the operation theatre and accepted illegal
gratifications.

Preliminary enquiry was ordered as per R.No. Spl/ E4/2002 dated

24.08.2002 of the Dean, Govt.Mohan Kumaramangalam Medical College
hospital, Salem.1 and the preliminary enquiry report dated 26.08.2002
established the charges prima facie, with the witnesses testifying to the
irregularities mentioned above.

Thus Thiru.P.Shanmugasundaram, M.N.A had committed corruption,

indiscipline and dereliction of duty as mentioned in the charges framed
above.

Brief statement of the Defense:-

In reply to charge 1, the delinquent M.N.A has stated that he is serving very
well with out any default in wound dressing and drug distribution for the
past 29 years. He has totally denied that he was irregular in his duties, failed
to dress the wound and apply medicines in time to the patients; and thus he
was not negligent in his duties.

In reply to charge 2, the M.N.A has stated that the allegation of smoking
while on duty is not correct. Since he is not in the habit of smoking within
the hospital campus in order to respect his superiors, this allegation is done
to tarnish him.

In reply to charge 3, the M.N.A has stated that he is pained to note this
allegation of corruption. In fact, he had helped poor patients out of his own
money. In such case, this allegation is not correct.
He has also stated that he had a long posting in the Orthopedics ward of this
hospital and he was not allowing the visitors at their will and used to send
the persons out of the ward, who are instrumental in making the ward untidy.
He has stated that he is of the opinion that someone who is jealous of him
might have made these allegations. He has also sought for personal enquiry
of the witnesses in his presence to prove his innocence.

Points for determination:-

1. Thiru.P. Shanmugasundaram, Male Nursing Assistant was irregular in his

duties, failed to dress the wound and apply medicines in time to the patients
and thus he was negligent in his duties.

2. Thiru.P. Shanmugasundaram, Male Nursing Assistant used to smoke

while on duty and even at the time of dressing the wound of patients, in spite
of their objections and thus he failed to follow the discipline and decorum of
a public servant.

3. Thiru.P. Shanmugasundaram, Male Nursing Assistant had demanded and

accepted money from the patients to provide treatment to them and thus he
indulged in corrupt activities, which is unbecoming of a Government
servant.

Assessment of evidence in respect of each point set out for determination

and the Findings on each articles of charge:-

As per the facts and documents examined during the course of the inquiry, I
hereby conclude that charge 1 framed against the M.N.A stands proved.

The charges 2 and 3 are not proved beyond doubt, as the persons who turned
up for enquiry had denied these allegations as far as they were concerned.
The other persons did not turn up for enquiry, even though the same persons
have testified the allegations in writing as correct at the time of preliminary
enquiry.
INCIDENT REPORT

 In a health care facility, such as a hospital, nursing home, or assisted

living, an incident report or accident report is a form that is filled out
 in order to record details of an unusual event that occurs at the facility,
such as an injury to a patient.
 Incident Report also a form, or screen, containing details of Incidents
involving any component of an IT Infrastructure or any aspect of the
IT Service. Incident reports may come from a variety of sources and
will usually result in the creation of an Incident record.
 Beside that, when an event occurs that harms an individual, illustrates
a potential for harm, or evidences serious dissatisfaction by patients,
visitors, or staff, then a risk-management incident has taken place.
Examples of such episodes could include the following:

 A patient's family helps him out of bed despite directions to the contrary
by staff members. The patient falls and is injured.
 Excessive silver nitrate is put into the eyes of a newborn, impairing
vision.
 The mother of the child complains about the care that has been given to
her child and informs a staff member that she is going to talk to her
lawyer about what has happened.

 When a member of the staff becomes aware of an incident, he has a

responsibility to make the hospital command aware of the situation.
The mechanism for doing this is the incident report system. Incident
reports are designed to promptly document all circumstances
surrounding an event, to alert the commanding officer, quality
assurance coordinator, and other involved administrators and
clinicians of a potential liability situation, and, in a broader sense, to
establish an information base on which to monitor and evaluate the
number and types of incidents that take place in the facility.
BIBLIOGRAPHY

 Basavanthappa BT, (2009), Nursing Education, New Delhi, Jaypee

Brothers medical publishers.
 Vati, Joginder. Principles and Practice of Nursing Management and
Administration. 1st edition, 2013, Jaypee Brothers Medical Publishers.
647-657
 CV guide – Massachusetts Institute of Technology – Global
Education & Career Development, United States
 Cover Letter guide – Massachusetts Institute of Technology – Global
Education & Career Development, United State