Nursing reports are a crucial part of the medical world. These are important tools that enable effective communication between the professional and patients, as well as between the healthcare team members; due to their importance, it is vital that all nurses learn how to write reports in an easy and appropriate manner.
The importance of report writing in nursing cannot be stressed enough since these reports allow future decisions to be made based on previous standards or experiences.
Without them, there would not be any way for potential problems to be predicted or averted, because they are used by many people such as doctors, administrators, etc. In this article, you will find out about types of records and reports in nursing among other things.
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The article takes you through report writing and the importance of report writing in nursing. There is a lot more you should know about your nursing report writing and this will be a guide to lead you through it.
Types of Report Nursing
This report will give you a general idea of what reports and records are used in nursing. If all the different types were mentioned, this article would be too long to read. Some of the items include:
a) Nursing incident report
To maintain a safe practice in medicine it is important that reports about any occurrences which may have affected your patients’ health or their care or treatment are recorded accurately and appropriately.
b) Nursing Observation Report
After taking observations as part of the normal assessment process, you may come across problems such as poor breathing rate, noticeable swelling, bleeding from a wound, or dizziness. These observations are recorded in nursing observation reports
c) Nursing Assessment Report
During your assessment of the patient, you may collect samples (e.g. urine sample), administer medications, perform procedures and make assessments that need to be documented on an inspection sheet and/or written report.
Kardexes are types of nursing reports that are made for a patient’s medical record. Kardexes are usually easier to read and follow when written in the form of a list, especially if there are many types of entries needing to be made.
e) Fluid Balance Report
The fluid balance report is one of the most important reports for a patient. This report shows how much liquid a patient is taking in (ingesting) and expelling (eliminating). In addition, information about intravenous fluids may be recorded on the fluid balance report.
f) Medical Summary Record
These records summarize information from several sources and integrate it into a single document to provide an overall picture of a patient’s status at a given time point.
g) Patient Condition Report
A Patient Condition Report, sometimes referred to as PCR or PSAR, allows staff members to find out what a patient is suffering from and what treatments have been administered to the patient.
Importance of Reports in Nursing
Reporting is a critical function of nursing because it provides information that may be used to improve care, decision-making, and research.
- It delivers information about the patient from an objective source.
- An active reporter can facilitate continuity of care using one report for communication within an episode of care.
- Another importance of report writing in nursing is that they provide a vehicle for communication of care from one shift to another.
- Systematic reporting facilitates continuity between shifts at the bedside and provides an organized system of communicating vital information about patients to all members of a health care team.
- Reporting can also be used as teaching of modality, furthering professional education and skills by writing reports that reflect assessment findings
The importance also varies with a specific condition or disease process and with different specialties. The importance may also vary based on the experience levels – importance decreases as staffs gain more experience. It increases again when staffs look back at earlier records and reflect upon their own clinical practice.
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How to Write a Nursing Report
You can easily write a report now that you know the importance of reports in nursing. You just need to follow these few steps.
a) Pick a Topic
It’s vital that you have a topic for writing your report. Plenty of topics are available to pick from, which makes this easy.
b) Write an Outline
Create an outline that will help you prepare for the report. Incorporate the necessary information in your outline and you’ll be able to easily write a report.
c) Write an Abstract and Introduction
An abstract is generally used at the beginning of any report, especially those that are written by researchers or other experts. It’s a concise summary of the main points that will be covered in a report without divulging details. This way, you can entice the readers to read on and learn more from your full report.
c) Write the Body of the Nursing Report
Here comes the most important part of nursing reports- the body. The main sections of a report are, usually, the introduction, discussion or outcome, and conclusion. A clear analysis is important in all these sections to properly explain your nursing evaluation.
d) Cite the Report Relevantly and Effectively
Citing the report correctly is important to show the importance of report writing in nursing. By citing the original report, you’ll be able to make it easier for your readers or audience to access the primary resource for further study.
Most reports have a proper format that can be easily used as a reference while composing your own nursing report.
e) Include Your Personal Analysis and Nursing Recommendation
This part would require you to present your opinion based on evaluation and analysis of the issue. Propose appropriate solutions like changes in policy, procedures, or other measures that should be implemented based on an accurate analysis of the current situation.
f) Write the Concluding Paragraph or Statement
The conclusion or summary summarizes what was stated in the introduction and the statement of the problem. In this portion of the report, you should state that solutions are possible and offer your opinion on the importance of implementing them.
The closing statement is to let the receiver know that all issues have been addressed in the report or letter.
g) Reference Page
The reference page at the end of the document shows a list of cited works and documents used in the making of the body of the report.
This is a must for use in term papers and essays because you should be interested in the works of other people and draw on their ideas to enhance your own writing skills. You can cite your source by indicating it below the quotation or information taken from them, together with its page number.
What a Good Nursing Report Should Contain
Writing a great nursing report is easy if you have all of the essential information at hand. That means having all of your paperwork correct, doing a thorough examination, and communicating with other people in a timely manner. A perfect nursing report should contain a few basic elements.
First, it needs to include a clear and concise reason for the report. This does not have to belong or be complicated (although it can be if you want). It needs to simply state what is happening at that moment or what care your patient needs at this time. You can even relate this directly back to the paperwork you completed prior to writing the report.
Secondly, every great report should include some information about how your patient’s health is doing at this time. This may be in the form of numbers such as temperature, weight, blood pressure, etc. or it may just be a brief statement about how your patient looks to you.
Finally, every report needs to include some instructions for the future care of the patient and what they need from you and other people involved (mostly other nurses).
This could include things like where to go next for their treatment or anything else that will keep them healthy while being treated in an institution like a hospital or nursing home.
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You Are Ready for Your Nursing Report Writing
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