RECORDS AND REPORTS

By: Ann Grethel R. Tan, RN

 Reports

are oral or written exchanges of information shared between caregivers or workers in a number of ways. A report summarizes the services of the person, personnel and of the agency. Reports are written usually daily, weekly, monthly or yearly.

A "paperless" patient record has special risk management issues that need to be considered. Many organizations are making the transition to a "paperless" patient record. Although the basic principles for documentation remain the same in a paperless system, maintaining the patient's right to privacy becomes a greater challenge. The first major guideline that must be established is the design of specific criteria for who can access patient information. Then, guidelines on the actual process of accessing patient information must be established..

 In

response to the demand for objective measures of quality, a number of health plans, healthcare providers, employer purchasing groups, consumer information organizations and state governments have begun to formulate healthcare quality report cards.

 In

point of facts, the scores that apply to specific providers may diverge significantly from plan wide scores (Grimaldi). In addition some critics of healthcare report cards point out that health plans may receive conflicting ratings on different report cards. This is result of using different performance measures and how each report card chooses to pool and evaluate individual factors.

 It

is to be written jointly by the manager and staff nurse. It should be reliable, valid and accurate, showing progress made by the nurse giving illustrations to substantiate value judgments. Any improvements are to be noted, and staff nurses should know exactly where they stand.

 Most

facilities use an incident reporting system to document accidents and errors. Incident reports are an integral part of a risk management program and help risk managers track conditions that might need to be corrected. Incident reports can help those in staff development identify education and training needs. Incident reports assist nurse managers in tracking and maintaining staff competencies.

 Nurses

should know what must be reported, complete the incident report in its entirety, be objective in reporting, include names of witnesses to the incident preserving the confidentiality of witness patients by using the patient's admission number, submit the incident report through proper channels, never refer to incident reports in a patient's record as the privilege of confidentiality can be waived, consult with nurse manager or the institution's risk manager when questions arise.

Permanent,

cumulative evaluation records can be used to assess how the nurse can best be used in the agency. They can be used as a basis for pay increases and promotions or termination.

 In the past, discipline meant rigid obedience to

rules and regulations, the violation of which resulted in punitive actions. Today, discipline is regarded as a constructive and effective means by which employees take personal responsibility for their own performance and behavior. Discipline is defined as influencing behavior through reprimand. Progressive discipline ties reprimand to the severity and frequency of the employees infractions. Positive discipline tries to involve people more positively and directly in making decisions to improve their behavior.

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A strong commitment to the vision, philosophy, goals, and objectives of the institution. Laws that govern the practice of all professionals and their respective Codes of Conduct. Understanding the rules and regulations of the agency. An atmosphere of mutual trust and confidence. Pressure from peers and organization.

 A sound disciplinary program must be tailored to

the objectives of the institution. This should include a set of disciplinary policies and procedures, a uniform application of discipline rules, a disciplinary committee, and an orientation program for all new employees where expectations of appropriate performance and behavior are emphasized. There must be continuous communication to all employees regarding changes in personnel and discipline policies. Changes must be communicated before these are affected.

 Have a Positive Attitude

The managers attitude is very important in preventing or correcting undesirable behavior. If personnel are treated as suspect, they are now likely to provide the trouble that the manager anticipates. People tend to do what is expected of them, therefore it is the managers duty to maintain a positive attitude by expecting the best from the staff.

 Investigate Carefully The ramifications of disciplinary action are so

serious that managers must proceed with caution. They should collect facts, check allegations, talk to witnesses, and ask accused employees for their side of the story.

 Be Prompt

Managers should not be so expeditious that they

neglect to be thorough in ascertaining the facts. If a staff nurse is disciplined unfairly or unnecessarily, the effects on the entire staff may be severe. However, if the discipline is delayed, the relationship between the punishment and the offense may become less clear.

 Protect Privacy Disciplinary action affects the ego of the staff

nurse. Thus it is better to discuss the situation in private.

 Focus on the Act When disciplining a staff nurse, the manager

should emphasize that it was the act that was unacceptable, not the employee.

 Enforce Rules Consistently Offending employees should be treated equally or

consistently for similar transgression. Equal treatment is based on rules with specific penalties for various acts and the number of offenses.

 Be Flexible Consistent implementation is complicated by the

fact that individuals and circumstances are never the same. A penalty should be determined only after the entire record of the employee is reviewed.

 Advise the Employee The employees must be informed that their

conduct is not acceptable.

 Take Corrective, Constructive Approach The manager should be sure that the staff nurse

understand that the behavior was contrary to the organizations requirements and should explain why such regulations are necessary. The staff should be counseled as to what behavior is required and how to prevent future disciplinary action.

 Follow Up The

manager should quietly determine whether the staff changed.

investigate to behavior has

 An employee charged for breach of the rules and

regulations, policies, norms of conduct shall be given due process. There must be existing rules of conduct governing his behavior and a documentation of actual violation of such rule must support charges. The employee charged must be notified in writing about the violation and given the right to counsel. Disciplinary action should be progressive in nature such as counseling and oral warning, written warning, suspension, and dismissal.

 Counseling and oral warning are best given in private

and in an informal atmosphere. The employee is given a fair chance to air his side. The relevant facts are analyzed and evaluated against his past performance. The employee is then counseled regarding expectations of improves behavior/ performance, ways of correcting the problem and a warning that a repetition of the same offense may warrant further disciplinary action. The employee must commit to correct the behavior. He should be informed of any follow up action that may be taken.

 It is preceded by an interview similar to the oral

warning. The employee must be told after the interview that he will be given a written warning. This includes the statement of the problem, identification of the rule which was violated, consequences of continued deviant behavior, the employees commitment to take corrective action, and any follow up action to be taken.

 Suspension

over minor violation is given after an evidence of oral and written warnings. Although a violation is a major infraction, suspension, rather than dismissal is applied when management feels that the employee can still be rehabilitated. Accurate documentation of oral and written warnings including suspension, if done, are necessary evidences of due process.

 Dismissal

is invoked only when all other disciplinary efforts have failed. The Disciplinary committee should be very sure that the cause for dismissal conforms with the criteria of a major discipline violation is contained in the policy manual, and for government employees, those contained in the Civil Service Rules and Regulations and the codes of conducts. A review is done by higher management.