ERIC Number: ED202546
Record Type: Non-Journal
Publication Date: 1977
Reference Count: N/A
Health Instruction Packages: Record-Keeping in Allied Health.
Andrews, Roberta L.; And Others
Text, illustrations, and exercises are utilized in this set of four learning modules designed to instruct nurses and nursing students in writing objective clinical reports. The first module, "Nursing Notes in POMR" by Roberta L. Andrews, discusses the four components of a nursing report written under the Problem-Oriented Medical Record System: patient comments; objective clinical observations, such as the pulse rate; the nurse's assessment of the patient's condition; and plans for following up on this assessment. The second module, "Patient Condition Reporting" by Malcolm MacDonald, discusses the writing of patient reports which include personal identifying information, immediate and long-range nursing needs, treatment order changes, equipment requirements, and environmental factors such as desired room temperature. The third module, "Incident Reports" by Gerry Kenny, defines incidents as accidents, thefts, or other abnormal occurances; examines methods of avoiding hearsay and subjectivity in describing incidents; and follows an incident report through channels. The fourth module, "How to Chart Nurses' Notes" by Kathleen M. Hopkins, discusses the writing of clear, unambiguous clinical observations of patients' health and behavior. Each of the modules provides reinforcement exercises with immediate feedback and concludes with a post-test and answer key. The modules require from 15 to 40 minutes to complete. (JP)
Publication Type: Guides - Classroom - Learner
Education Level: N/A
Sponsor: Kellogg Foundation, Battle Creek, MI.
Authoring Institution: League for Innovation in the Community Coll., Los Angeles, CA.