UNIT – 8 REPORTING AND RECORDING

Communication

Introduction

“Communication is the process in which a message is transferred from one person to other person
through a suitable media and the intended message is received and understood by the receiver.”

Every organization whether business or non-business has some specific goals and stakeholders.
Attainment of those goals depend on successful communication with the respective stakeholder
groups. Therefore, communication is considered as the part and parcel of any organization.

Organizational communication is the exchange of ideas, information and views within and outside
the organization.

“Organizational communication is the flow of messages within a network of interdependent

relationships.”

Communication in Administration

Nurse's managers are required to be aware of the techniques that can help them to ensure effective
management of educational/service unit. Communication is the foundation upon which the
manager achieves organizational objectives.

Flow/ element of communication

 Sender: Firstly the message sender decides to develop an idea or selects information,
content or message to share with someone.
 Encoding: In this stage the sender puts the idea into symbolic forms like speaking,
writing or non- verbal behavior to share with someone.
 Message: It is the idea, information, view, fact, feeling, etc. that is generated by the
sender and is then intended to be communicated further.
 Media: Transmission of message must overcome by interference such as garbled speech,
unintelligible use of words, illegible hand writing, long complex sentences etc.
 Receiver: The receiver’s senses of seeing and hearing are activated as the transmitted
message is received. Receiver tend to have selective attention like some hear the message
of their interest but no other, some hear the parts of message in which they are interested.
The receiver may preoccupied with other activities and consequently not be ready to listen.
 Decoding: This is the critical stage of communication process. This process is depends
on the receiver's understanding of the information. Written messages allow more time for
decoding, as the receiver assesses the explicit meaning and implications of the message
based on what the symbols mean to him/her.
 Response or feedback: It is the final step. It is important for the manager or sender to
know that the message has been received and accurately interpreted.
Structure of communication

1. According to organizational structure

 Formal
 Informal
2. According to direction
 Upward
 Downward
 Horizontal/ lateral
 Diagonal
 External

1. According to organizational structure

 Formal communication

 Formal communications are the communication which flows through the official
channels designed in the organizational chart.
 It may take place between a superior and a subordinate. E.g. Manager asks his/her
employee to do a task.
 These communications can be oral or written, generally recorded and filed in the office.
 It can be further classified as vertical and horizontal communication.

 Informal communication

 Informal communications are the communication that takes place without following
the formal channel of communication.
 The informal communication spreads rapidly, often gets distorted and it is very difficult
to detect the source of such communication.
 It also leads to rumors which are not true.
 E.g. Employees conversation during launch, or interaction between two close friends.
2. According to direction

 Upward communication

 Communication that flows to a higher level in an organization is called upward

communication. I.e. from subordinates to superiors.
 It can be in the form of suggestion, complaint, report etc.
 E.g. application for leave
 The subordinates use upward communication to convey their problems and
performance to their superiors.
 It can also be used by the employees to share their views and ideas and to participate
in the decision- making process.
 It can be oral and written such as face to face communication, interview, telephonic
conversation, meetings and conferences.
 Downward communication

 Communication that flows from a higher level in an organization to a lower level is

called downward communication. I.e. from superior to subordinates.
 E.g. from nursing superintendent to nursing staff.
 This communication is used by the managers to transmit work related information to
the employees at lower levels.
  It may be oral or written such as lecture, conference meeting, interview, counseling,
telephone, wall posters.

 Horizontal or lateral communication

 Horizontal communication is the transmission of information between people,

divisions, departments or units within the same level of organizational hierarchy.
 E.g. between peers, between managers at same levels.

 Diagonal communication

 Communication that takes place between managers or employee with other managers
and employees from other department who are not at same level is called diagonal
communication.
 It is less formal and involves only giving advice not giving directives.

 External communication

 Communication that takes place between a manager and external groups such as
suppliers, banks, financial institutes etc.
 E.g. for instance- to raise capital the managing director would interact with the bank
manager.

Methods of communication

The common methods used for transmitting the message are as follows;

1. Verbal
2. Non- verbal
3. Written

1. Verbal communication

 In verbal communication, information is sent or shares directly either dace to face or

through telephone.
 Managers use this form of communication in giving direction for immediate actions and
feedback to the employees, in setting disputes among employees, in having formal and
informal situations.
 In an organization Verbal communication use in formal situations include meetings,
lecture, conferences, seminars, telephone calls, workshops, interviews, speeches and
presentations.
2. Written communication

 In written communication, information is sent in written form. It can take the form of
statement, letter, circular, handbook, manual report.
  Managers use this form of communication to send information that requires some future
action, for the circulation of information.
 It is always put in black and white.
 It is typically more formal but less efficient than verbal communication.

3. Non- verbal communication

 Non- verbal communication is transmission of message without using words, neither

verbally nor in writings.
 It is expressed through body language, body position, facial expression and body
movements.

Barriers of communication in organization

 Semantic barriers:

These are concerned with the problems and obstructions in the Process of encoding and
decoding of a message into words or impressions. Normally, such barriers result due to use
of wrong words, faulty translation, different interpretations, etc. For example, a manager
has to communicate with workers who have no knowledge of the English and on the other
side; he is not well conversant with the Nepali language. Here, language is the barrier to
communication as the manager may not be able to communicate properly with the workers.

 Psychological barriers:

Emotional or psychological factors also act as barriers to communication. The state of mind
of both sender and receiver of communication reflects in effective communication. A
worried person cannot communicate properly and an angry recipient cannot understand the
message properly.
Thus, at the time of communication, both the sender and the receiver need to be
psychologically sound. Also, they should trust each other. If they do not believe each other,
they cannot understand each other's message in its original sense.

 Organizational barriers:

The factors related to organizational structure, rules and regulations authority relationships,
etc. may sometimes act as barriers to effective communication. In an organization with a
highly centralized pattern, people may not be encouraged to have free communication.
Also, rigid rules and regulations and cumbersome procedures may also become a barrier
to communication.

 Personal barriers:

The personal factors of both sender and receiver may act as a barrier to effective
communication. If a superior thinks that a particular communication may adversely affect
his authority, he may suppress such communication. Also, if the superiors do not have
confidence in the competency of their subordinates, they may not ask for their advice. The
 subordinates may not be willing to offer useful suggestions in the absence of any reward
or application for a good suggestion.

Advantages of proper or two-way communication

 Smooth communication

Two way communication ensures that there are no hindrances in respect to the flow of
message and feedback. The sending party can smoothly transfer the message through a
channel. The receiving party too can respond to that message without facing any
difficulties.

 Proper execution of superior’s directions

The role of two-way communication is vital in every organization as it allows the

employees or subordinates to ask clarificatory questions from the superior. This ensures
that whatever instruction, direction, policy or order the superior has given is appropriately
executed. This way, any misunderstanding regarding the can be quickly cleared away.
 Employee suggestions

Suggestions from employees are significant if an organization is looking for making some
progress. Sometimes employees have great ideas to recommend that can help to improve
the company’s policies and plans.

 Effective communication

Communication becomes effective when the information is comprehended well by both

the parties involved. It ensures that this to evaluate and assess each other’s effectiveness is
maintained by allowing the sender and the receiver
stances.

 Job satisfaction

In two-way communication, employees of an organization can be demonstrative about

what they feel, what their interests are, and what all complaints and opinions they have.
All this can be effectively conveyed to their superiors. This enables the superiors to take
the required measures for promoting the employees’ welfare. All these efforts help in
increasing the sense of job satisfaction among the organization’s employees.

 Clear message

When an organization follows the two-way communication model, there is hardly any
chance of ambiguity. If the receiver faces any confusion regarding the message, they can
quickly contact the sender to get some clarity.
 Record

Concept and Meaning

A record is a permanent written communication that documents of information relevant to a

client’s health care management, e.g. a client chart is a continuing account of client’s health care
status and need.

A record is a clinical, scientific, administrative and legal document relating to the nursing care
given to individual, family or community. Facts record have a value and scientific accuracy for
more memory impression and guidelines for better administration of health services.

All documented information, regardless of its characteristics, media, physical form, and the
manner it is recorded or stored. Record include accounts, agreements, books, drawings, letters,
magnetic/optical disk, memos, micrographics, etc. Generally speaking records function as
evidence of activities. Records are the means of communications between health workers and their
client.

Examples of records;

 Information captures in the organization’s various database.

 Physical paper in our files as memos, contracts, marketing materials and reports.
 Electronic message such as email content and their attachments and instant messages.

Purposes of records

 Records provide data for program planning and evaluation.

 Record indicate plan for future.
 Records are the tools of communication between the health workers, the family and other
development personnel.
 Record provides baseline data to estimate the long-term changes related to services.
 Records provide an opportunity for evaluating the services.
 Record help in the research for improvement of nursing care.

Principles of records

 Record should be written clearly and appropriately.

 Nurses should develop their own method of expression and form in record writing.
 Record should contain facts based on observation, conversation and action.
 Select relevant facts and the recording should be neat, complete and uniform.
 Record should be written immediately after an interview.
 In documentation confidentiality should be maintained.
Importance of Records in Hospital and Community Health agencies;

A medical record should furnish all health care providers with concise, accurate, written picture of
patient’s medical and nursing problems and the patient’s response to the treatment. Nurses must
understand how to use these records effectively and efficiently.

1. Hospital

 It provides statistical information like birth, death, hospital admission, discharge,

inpatient and outpatient record, etc.
 It helps in administration control by helps an organization to keep the necessary
documentation assessable for both business operations and compliance audits.
 It helps in evaluation of care in terms of quality, quantity and adequacy.
 It helps supervisor to evaluate service.
 It is legal evidence of service render by each employee.
 It provides justification of expenditure of funds.
 It helps in making studies for research, for legislative action and for planning budget.
 It provides the management with statistical information necessary for the decision in
regard to utilization of resources, planning of administrative control and future
reference.

For doctors
 It indicates progress and continuity of care.
 It helps in self-evaluation of medical practice.
 It protects the doctor in legal issues.
 It is used for teaching and reading.
 It serves for diagnosis, treatment, follow up and evaluation.

For nurses
 It provides data essential for planning and evaluation of services for further
improvement.
 It helps in guidance for professional growth.
 It judges the quantity and quality of work done.
 It serves as a communication tool between nurse and staff involved in care.
 It shows progress and indicates plan for future.

2. Community Health Agencies

Records of daily activities is kept by community health nurse. It gives information about
the following:
 Name of village and head of each family
 Distance of village/community from health center
 Total number of families in community
 Total population residing in community
 Religious beliefs and values followed by community people
  Records of vulnerable and privilege group in the community
 Community health institution and its activities
 Number of schools located in community
 Environmental condition of the community
 Local resources available for sustainable development in community
 List of eligible couple and child register
 Reports of vaccination and test
 Incidence and Prevalence of any disease condition.

NURSING RESPONSIBILITIES OF RECORD

 Record should be written clearly and appropriately.

 Information should have a logical manner
 Keep all record in safe custody.
 Records should be written immediately after an interview.
 Shared only be health team members, no stranger should be allowed to visit record room.
 Never allow anyone to take file outside the ward.
 Records are not to be handed over to any legal advisor without written permission of the
administration.
 Each record should be signed by the nurses. Signature includes the name and the title.
 REPORT

Concept of Reports

“Report” is derived from the Latin word “reportare” which means carry back.

"Re" means "back" and "portare" means "to carry".

Reports are oral or written exchanges of information shared between caregivers or workers in a
number of ways. Reports are usually written daily, weekly, monthly or yearly. Report summarizes
and analyses the service of the nurse and or the agency.

The purpose of reporting is to communicate specific information to person or group of people. A

report, whether oral or written, should be concise, including pertinent information but no
extraneous details.

Definition of Nursing reports

"Reports are information about a patient either written oral."

- Sr. Nancy

"A report is a summary of activities or observations seen, performed or heard."

-Potter & Perry

Purpose of reporting

 To show the kind and amount of services rendered over specified period.
 To illustrate progress in reaching goals.
 To aid in studying health conditions.
 To aid in planning.
 To interpret the services to the public and to the other interested agencies.
 To provide quality and continuity of work from one shift to another.
 To avoid the duplication of work.
Criteria of good report

 Can be made promptly

 Clear, concise and complete
 All pertinent, identifying data included
 Mention all people concerned, situation and signature of person making report.
 Easily understood
  Important points are emphasized.

Importance of reporting

 Reports can save duplication of effort.

 Patients receive better care when reports are thorough 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.
 It increases teamwork and relationship among the nurses in different shifts and units and
decrease the potential for mistakes.

Reports may be classified as oral and written:

1. Oral report
Oral reports are given when the information is for immediate use and not for permanency
(like report on patient's comfort from nurse to nurse).

2. Written report

Reports are to be written when the information is to be used by several personnel, which is
more or less of permanent value, for example day and night report, Census,
interdepartmental reports and other special report, needed according to situation, events
and conditions.

The reports used in hospital setting usually are change- of- shift reports, transfer reports,
incident report, day, evening and night reports, legal reports.

1. Change-of-shift reports

These may be given in orally in person by audio taping, recording, or during rounds at the
client's bedside some of the points to be kept in mind while giving such reports are as
follows:
 Provide only essential background information about client (name, sex, age,
diagnosis and medical history).
 Identify client's nursing diagnosis or health care problems.
 Share significant information about family members, as it relates to client's
problems.
 Relay to staff significant changes in the way therapies are given. Do not describe
the basic step of procedure.
 Evaluates result of nursing or medical care measures. Do not simply describe results
as good or poor. Be specific.
2. Transfer reports

Patients will frequently be transfer from one unit to another to receive different levels of
care. A transfer report involves communications of information about clients from the
nurse on sending unit to the nurse on the receiving unit.

When giving transfer request, nurse should include the following information.

 Client's name, age, primary doctor, and medical diagnosis.

 Summary of medical progress up to the time of transfer.
 Current health status-physical and psychosocial.
 Current nursing diagnosis or problems and care plan.
 Any critical assessment or inventions to be completed shortly.
 Needs any special equipment.

3. Incident reports

Nurses usually become involved in client related indents as some point in their careers.
They must understand the purpose of incident reports and the correct way to report
information. While reporting any incident, the following point to be kept in mind.

 The nurse who witnessed the incidence or who found the client at the time of
incident should file the report.
 The nurse describes in concise what happen specifically objection, term, etc.
 The nurse does not interpret or attempt to explain the cause of the incident.
 The nurse describes objectively the clients, condition when the incident was
discovered.
 Any measure that are taken by the nurse, other nurses or doctors at the time of
incidence are reported.
 No nurse is blamed in an incident report.
 The report is submitted as soon as possible to the appropriate authority.
 The nurse should never make photocopy of the incident report.

4. Legal reports

Incident reports and reports on accident, mistakes and complains are legal in nature. When
a hospital is criticized or claimed for negligence or poor care because of a condition that
resulted in discomfort and perhaps serious harm to a patient or client, the reports,
containing briefly and objectively giving all pertinent information. Accuracy, timelines,
completeness and relevancy to the problems are maintained promptly while making such
reports.
NURSING RESPONSIBILITIES OF REPOTING

 Report should be well written, clear and specific.

 No report should be sent out of the ward.
 Report should be handled carefully.
 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 manger.
 Accuracy; A client record must be reliable information must be accurate so that health team
members have confidence in it.
 After writing reports, nurse must sign.
 No stranger should be allowed to read.
 Meeting

Introduction

A group of people meeting together in a different place at a given time to discuss on certain agenda.
It is an important activity of management to bring consensus decision making.

Definition

A meeting is a gathering of two or more people to present or exchange information, plan, decision
making or to carry out actions already agreed upon.

One dictionary defines a meeting as an act or process of coming together as an assembly for a
common purpose.

Types of meeting

The primary step to come up with an effective meeting is by defining what type of meeting it is,
whereas each meeting is unique which can assist better in determining the goals, structure and
activities best to the organization. There are different types of meeting:

1. Staff meeting

This meeting is called by directors and administrators and its point is to keep all members
of the staff educated on the present issues that influence them to the work place including
issues that influence their area of expertise.

2. Team building meetings

It is designed to focus on team building activities for strengthening relationships. This

category includes meetings like corporate events, kick off meetings, all hands meeting as
well as team building outings. Such meetings enhance motivation, worker satisfaction and
performance.

3. Status update meeting

Most companies have updated meeting after a stipulated period for instance on a weekly
or monthly basis. The main goal of this type of assembly is to provide employee update on
the company’s challenges and progress.
 4. Emergency meeting

A meeting of urgency is convinced if the organization is experiencing a serious problem,

for instance if a significant financial loss has occurred, it is important to inform all the
employee so that they understand the changes and implication that will occur as a result of
emergency.

5. Decision making meeting

In this type of meeting, those who are invited make the vast majority of business decision.
All those involved in sitting should be much aware of what they are going to discuss to
make sure the decision they have reached on the meeting is worthwhile.

6. Motivational meetings

It is designed to gain commitment from a group or team of workers around the change
effort. Such meetings are held to uplift the energy and the will of participants to meet a
particular target.

Methods of conducting meetings

1. Before meeting

a) Check the items before conducting meetings

b) List the name of members, visitors, observers, advisors and members who are absent.

2. During meeting

c) Open the meeting by chairperson on time, greet and welcome the participants.
d) Explain the purpose, objectives, agenda and subject matter.
e) Follow the agenda and subject matter, point by point.
f) Make control to group through ground rules and maintain respect given equal chance
to speak everyone, discuss, accept and agree upon it, control timing, personal and
irrelevant remark.
3. After meeting

g) Appropriate record of exact wording of any special decision made by group.

h) Summarize the agenda, discussion and decision, time, date, place of next meeting,
normally minutes are approved but some changes occur sometimes.
i) Write up all proceeding and distribute the copy to all members if possible.
j) Read previous meetings, minutes and ask for its clarifications if necessary.
 MINUTES

Minutes is an official written statement of the motions and resolutions taken in meeting.

It is also defined as the official record of the proceeding of a meeting that should be needed to
approve by the participating members of the meeting.

“Minutes are the official record of the proceeding of meeting’’.

- (Rajendra pal and korlahali)

TYPES OF MINUTES

1) Minutes of resolution

Minutes of resolution means the written statement of the decision that have been taken and
approved by the participating members of the meeting. Only the main conclusions which
are reached at the meeting are recorded in minutes of resolution. These are usually used for
minutes of Annual general meetings (AGMs) and other statutory meetings.

2) Minutes of narration

This is difficult; the writer is required to summarize what is being said as it is being said.
These minutes will be a concise summary of all discussions which took place, reports
received actions to be taken and decision made.

CONTENT OF MINUTING

It includes;

 Names of the participating members

 Names of the proposer and supporter
 Discussions summary and resolution

GUIDELINES FOR MINUTING

1. Meeting basic like name, place, date and time.
It include basic details about your meeting at the top of meeting minutes document .This
ensures that everything is organized and that your meeting can be identified at a glance.

2. List of meeting participants.

It include a list of everyone who was present at meeting. It identifies everyone who’s
working on or involved with a given project or topic as well as nothing down which
employees are informed about.
 3. Meeting purpose
Every meeting should have one central goal. You might discuss a variety of topics but
there should be one main objective on the agenda. It is essential to note this down because
it helps provide direction to the meeting and clarity regarding its focus.

4. Agenda items
Meeting minutes should include all the agenda items that were addressed at a meeting.

5. Next meeting date and place

At the end of the meeting your team should determine how long it will be until everyone
needs to meet again. Make sure to note down the date and time in your meeting minutes.

6. Documents to be included in the meeting report.

In addition, of meeting document that will be needed to attach to report and refer back to
In the future. So this might include reports, presentation and documentation and so on.

BENEFITS OF MINUTES
1. The minutes will be enable the participants to check whether official decision have been
implemented correctly.

2. It also serves as a source of the information for those that did not attend the meeting of what has
been taken place.
3. Once minutes are signed they have legal value.
 References
 Bariya R.K.S. (2078).Leadership & Management in Nursing (second edition).Bag bazar,
Kathmandu: Samiksha Publication Pvt.Ltd.
 Pathak S. (2018).A Textbook of Foundation of Nursing (first edition).Bhotahity,
Kathmandu: Vidyarthi Pustak Bhandar Publisher and Distributors.
 Albouy, L. (2021, October, 20).How to write helpful meeting minutes.
Sitehttps://slite.com/learn/meeting-minutes
 Doris, M. (2019, march, 21). Importance of report writing in nursing.
Academichttps://www.academicwritersbureau.com/blog/407-importance-of-report-
writing-in-nursing
 Brar, J.K. (2015, july 30).Nursing records and reports.
Slideshare.https://www.slideshare.net/jasleenbrar03/nursing-records-reports