RUFAIDA COLLEGE OF NURSING, JAMIA HAMDARD

ASSIGNMENT
ON

ANECDOTES, INCIDENT REPORTS, DAY AND NIGHT

REPORTS, HANDING AND TAKING OVER REPORTS,

ENQUIRY REPORTS, NURSES NOTES, OFFICIAL

LETTERS, CURRICULUM VITAE

SUBMITTED TO: SUBMITTED BY:

MS. JAMAL FATIMA MS. DEEPTI KUKRETI

ASST. PROFESSOR M.Sc.(N) 2ND YEAR

RCON RCON

SUBMITTED ON:

17-04-20

ANECDOTAL RECORD
INTRODUCTION:

 Anecdotal record is a one of the method for assessing clinical performance of the
student’s behavior observed by teacher.
 It is a verbal snapshot of the incident. Episodes of student behavior are recorded
periodically in relation to the educational outcomes as specified by the learning
objectives.
 This allows the instructor to chart student progress in varies area by making
comparisons over time in a variety of situations.

DEFINITIONS:

 Anecdotal record is a record of some significant item of conduct a record of an

episode in the life of student, a word picture of the students in action a word snap shot
at the moment of the incident, any narration of events in which maybe signified about
his personality. ( Randall)

 Anecdotal record, as the name implies, involve setting

down an anecdote concerning some aspects of students behaviors which
seems significant to the observer. (Tandler)

PURPOSES:

 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 individuals basic personality pattern and his reactions in different
situations.
 Helps the students to improve their behavior, as it is a direct feedback of an entire
observed incident, the students can analyze his behavior better.
 Useful in supplementing and validity observations made by other means.
 It can be used by students for self-appraisal and peer assessment.
 It can be used as a appraisal performance method by the supervisors for their staff
evaluation.

CHARACTERISTICS:

 Each anecdotal record should contain a record of a single incident.

 The incident recorded should be that is considered to be significant to the pupil’s
growth and development.
 What is written down is & what was seen or heard. Inferences, guesses, or
assumptions are omitted unless they are clearly labeled as Inferences, guesses, or
assumptions.
  The observer has determined what aspects of behavior are related to the dimension
being appraised. He observes these only and records these only.
 If the recorded is to be cumulative, a plan of periodic observation and recording is
established and adhered to.
 Words or phrases are used whose meaning is clear.
 It is used for obtaining data pertinent to a variety of learning outcomes and many
aspects of personal and social development.
 The interpretations and recommended actions should be noted separately from the
description.
 Words and phrases that have strong emotional connotations are avoided. i.e love ,hate,
insolent, courteous, loyal, dishonest etc.
 Words and phrases are avoided which express the opinion. Terms that should be
avoided are these: Well behaved, Delinquent, Aggressive, Didn’t cry, Industrious,
Nervous & Happy.

PRINCIPLES:

 Specify the behavior to be assessed in advance.

 Restrict observations to those aspects of behavior which can’t be evaluated by other
means.
 Concentrate on only one or two behaviors’.
 Observation should be selective. Limit the observations to those categories or
qualities.
 In observation, blue print or guide should be prepared in advance.
 Records should be complete.
 Record the incident or action as soon as possible after it has happened.
 They should be complied and filled.
 They should have an interpretative value.

STEPS IN ANECDOTAL RECORD PLANNING:

1. Enlisting the cooperation of the faculty, including counselors, and development of an

understanding and acceptance of the ideal of individualized education.
2. Deciding how much should be expected of observers who write anecdotes, possibly a
reasonable minimum number per week.
3. Preparing forms, which are usually simple.(anecdotes are best recorded on cards. Each
anecdote may be recorded on a single small card, or as in sometimes preferred, several
anecdotes may be recorded on one large card. In any case cards are most convenient
means of record-keeping since they are easy to file, sort and handle.)
4. Obtaining the original records, including a plan for jotting (brief, informal notes)
down the name of the pupil and an appropriate catch word at a time of the incident,
with a period set aside toward the end of the day for recording the anecdotes concerning
significant behavior episodes observed during the day. To be most useful anecdotal
 records on pupil should be kept over an extended period of time. To obtain a reliable
sample of a child’s behavior and to make any useful assessment of changes that can
occur, it is essential that adequate number of anecdotes or observations be made.
5. Central filing- in order that incidents described by different observers over a period of
time maybe assembled and compared to note trends.
6. Interpreting and summarizing, preferably under topical headings.
(if the anecdotal records are to be valuable they must be used, and if they are to be
used they must first be interpreted. To interpret the records it is of course necessary to
study and summarize them. Several anecdotes on a single student must be studied
and compared. They tell story, reveal characteristic behavior, show the
individual in his reaction with others in a natural setting. The task of interpreting
and summarizing is not an easy one. It invariably takes time and thought.
Summarizing and interpretation of the anecdotes should be done by the teacher who
has done the recording, though it can be done by a committee of 2 or 3 teachers,
especially in difficult cases. The guidance teacher, counselor or the school
psychologist may be bought into the picture if needed.)

SAMPLE OF ANECDOTAL FORM:-

NAME OF THE SCHOOL/

COLLEGE----------------------------------------

Name of the Student Observed Class

Subject

----------------------------------------- -- -------
- ----------

Name of the Observer

Date and Place
---------------------------------
------------------------

INCIDENT
Objective Description
It is an unplanned event within the scope of this procedure that causes, or has the potential to
-------------------------------------------------------------------------------------------------------------------------
cause, an injury or illness and damage to equipment, buildings, plant or the natural
environment.
Types of incident

There are mainly three types of incidents

● Near miss

● Adverse events

● Sentinal events

1. Near miss -This is where the incident did not result in harm, loss or damage, but
could have, this is referred to as a ‘near miss’. This may be clinical or non-clinical.
Near miss reporting is just as important in highlighting weaknesses in systems,
policies/procedures and practices. If near misses are reported and learnt from and any
necessary corrective action taken, they can help to prevent actual incidents of
harm,loss or damage from occurring. Near miss should be reported with in 24hrs of
working days.

2. Adverse events adverse incident (clinical)- An event or circumstance arising during

clinical care of a patient that could have or did lead to unintended or unexpected
harm’. Adverse incident (non-clinical) ‘an event or circumstance that could have or
did cause unexpected or unwanted harm, loss or damage to any individual(s) involved
(including patients but not related to clinical care, staff, visitors etc) or damage to/loss
of property/ premises in the hospital . It should be reported with in 2 hrs.

3. Sentinal events- An unexpected incident, related to system or process deficiencies,

which leads to death or major and enduring loss of function for a recipient of
healthcare services. It should be reported immediately.

How to report an incident

● Obtain the proper forms from the institution. Each institution has a different protocol in
place for dealing with an incident and filing a report.

● Start the report as soon as possible. Write it the same day as the incident, if possible,
because if we wait a day or two the memory will start to get a little fuzzy. Write down the
basic facts that need to remember as soon as the incident occurs, and do report write-up
within the first 24 hours afterward.

● Provide the basic facts. The form may have blanks for you to fill out with information
about the incident. If not, start the report with a sentence clearly stating the following basic
information given in the incidence form.
● Write a first person narrative telling what happened. For the meat of the report, write a
detailed, chronological narrative of exactly what happened when you report to the scene.
Use the full names of each person who is included in the report, and start a new paragraph to
describe each person's actions separately.

● Be thorough. Write as much as one can remember - the more details, the better. Don't
leave room for people reading the report to interpret something the wrong way. The
important thing is to report a complete picture of what occurred.

● Be accurate. Do not write something in the report that aren't sure actually happened.

● Be clear. Don't use flowery, confusing language to describe what occurred. The writing
should be clear and concise. Use short, to-the-point, fact-oriented sentences that don't leave
room for interpretation.

● Be honest. Even if you're not proud of how you handled the situation, it's imperative that
you write an honest account. If you write something untrue it may end up surfacing later,
putting your job in jeopardy and causing problems for the people involved in the incident.

● Submit your incident report. Find out the name of the person or department to whom your
report must be sent. When possible, submit an incident report in person and make yourself
available to answer further questions or provide clarification.

● Person responsible for the immediate management of the incident the person responsible
for the immediate management of the incident (e.g. The nurse in charge of the ward at the
time an incident occurs), should undertake an immediate assessment of the situation, in
order to determine any immediate treatment and/or ongoing care needs of the affected
person, and/or the extent of any loss/damage to property and any other immediate action
required (e.g. Removal and isolation of faulty equipment). The situation/scene should be
made safe.
 OFFICIAL LETTERS

INTRODUCTION
Informal letters may have been the easier question to answer during an examination,
but people can agree that formal or official letters hold a larger importance in our lives. There
is a standard format that all official letters have regardless of the subject matter. Official
letters are not to be confused for business letters. In order to understand the difference, search
for an official letter sample online. There are a number of options available for your benefit!

OFFICIAL LETTER:
Letters written with the intention of addressing complaints, queries; applications for
jobs, leaves, permission or to officials for certain obligations, government purposes, or a
simple correspondence between two institutions comprise official letters. They are written
with very specific intent and purposes, addressing necessary concerns and requests.

IMPORTANCE OF OFFICIAL LETTERS

 It is very important to know how to write an official letter format, since it is based on this
format that major aspects are addressed.
 There are many situations that arise in which an individual may need to address a variety
of issues with an institution or when applying for their first job.
 A well written letter holds more weight than one would imagine; it definitely weighs on
your ability to land the job you want. The importance of an official letter cannot be
understated. In order for your letter to be appreciated and noticed, it has to be
exceptionally well written.
 Mastering the art of writing a good letter for official purposes will prove to be extremely
beneficial in the long run.

PURPOSES:

 They serve as a means of communication between two institutions, an individual and

an institution, heads of department, etc.
 Business proposals, invitations and requests can be made via these letters.
Professional  official letter template can easily accommodate company letterheads and
logos which makes them perfect for business correspondence.
 Used for requests and appreciation of various services.
 Important for letters of introduction, cover letters, etc.
 Serve as a source of evidence and documented proof for legal proceedings or simply
to clear any misunderstandings.
 Provides information regarding official conversations and transactions that have
occurred between two consenting parties.
 It promotes and sustains a sense of goodwill.
 Establishes a means of communication and connection between those in
correspondence.
 Good format engages the reader and draws them towards the point of importance.
 In reference to CV’s and cover letters, it establishes communication skills.
 It showcases professionalism and establishes grounds for any communication.
 Could provide a preventive measure or solution to a problem that has not been
previously addressed. Thus, brings to light many issues that may not have been
noticed.

To,

The principal

All India Institute of Medical Sciences

New Delhi

Subject: Seeking formal permission for conducting research study in your Institute.

Sir/Madam,

This is to introduce Ms. Deepti Kukreti, a final year Master of Nursing student of this
college, in the process to conduct a research which is to be submitted in partial fulfilment of
the university requirements for the award of Master of Nursing Degree.

Topic: A pre-experimental study to assess the effectiveness of National Guidelines for

Diagnosis and Management of Gestational Diabetes Mellitus (GDM) developed By
Ministry of Health & Family Welfare (MoHFW) in terms of knowledge of nursing
educators in selected colleges of nursing New Delhi.

The student is in need of your kind help and co-operation as she is interested in conducting,
her study in your institute for which all necessary help may please be extended.

Thanking you in anticipation

With kind regards,

Prof. Urmila Bhardwaj

Principal

Prof (Dr.) manju chhugani

 HANDING AND TAKING OVER REPORTS

DEFINITION

The process of passing patient-specific information from one caregiver to another for the
purpose of ensuring patient care continuity and safety – (WHO & JCI, 2007)

AIMS

The aim of clinical handover is to ensure the accurate and timely transfer of information,
responsibility and accountability. Handover is to ensure that a timely, relevant and structured
clinical handover occurs that is appropriate to the clinical setting and context of the handover.
OBJECTIVES
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.
Before giving patient’s nursing records should includes the following

 The nursing record is where nurses write down what nursing care the patient receives
and the patient's response to this, as well as any other events or factors which may
affect the patient's wellbeing. These ‘events or factors’ can range from a visit by the
patient's relatives to going to theatre for a scheduled operation.
 If nurses are in any doubt about what to write down, nurses should look after the
following points:
a) If I am able to give a verbal handover to the next nursing team, or the next shift.
b) What would other shift nurses need to know in order to continue to care for my
patients.
c) Whether the patient's care is not affected by the changeover of nursing staff.

Keep good nursing records for effective day and night nursing reports
The patient's record must provide an accurate, current, objective, comprehensive, but concise,
account of his/her stay in hospital. Traditionally, nursing records are hand-written.

1. Use a standardized form. This will help to ensure consistency and improve the quality
of the written record. There should be a systematic approach to providing nursing care
(the nursing process) and this should be documented consistently. The nursing record
should include assessment, planning, implementation, and evaluation of care.

2. Ensure the record begins with an identification sheet. This contains the patient's
personal data: name, age, address, next of kin, career, and so on. All continuation
sheets must show the full name of the patient.

3. Ensure a supply of continuation sheets is available.

 4. Date and sign each entry, giving your full name. Give the time, using the 24-hour
clock system. For example, write 14:00 instead of 2 pm.

5. Write in dark ink (preferably black ink), never in pencil, and keep records out of
direct sunlight. This will help to ensure they do not fade and cannot be erased.

6. On admission, record the patient's visual acuity, blood pressure, pulse, temperature,
and respiration, as well as the results of any tests.

7. State the diagnosis clearly, as well as any other problem the patient is currently
experiencing.

8. Record all medication given to the patient and sign the prescription sheet.
9. Record all relevant observations in the patient's nursing record, as well as on any
charts, e.g., blood pressure charts or intraocular pressure phasing charts. File the
charts in the medical notes when the patient is discharged.
10. Ensure that the consent form for surgery, signed clearly by the patient, is included in
the patient's records.
11. Include a nursing checklist to ensure the patient is prepared for any scheduled surgery.
12. Note all plans made for the patient's discharge, e.g., whether the patient or carer is
competent at instilling the prescribed eye drops and whether they understand details
of follow-up appointments

According to writing tips by Dianne Pickering, 2002

1. Ensure the statements are factual and recorded in consecutive order, as they happen.
Only record what you, as the nurse, see, hear, or do.

2. Do not use jargon, meaningless phrases, or personal opinions (e.g., “the patient's
vision appears blurred” or “the patient's vision appears to be improving”). If you want
to make a comment about changes in the patient's vision, check the visual acuity and
record it.

3. Do not use an abbreviation unless you are sure that it is commonly understood and in
general use. For example, BP and VA are in general use and would be safe to use on
records when commenting on blood pressure and visual acuity, respectively.

4. Do not speculate, make offensive statements, or use humour about the patient.
Patients have the right to see their records!

5. If you make an error, cross it out with one clear line through it, and sign. Do not use
sticky labels or correction fluid.

6. Write legibly and in clear, short sentences.

7. Remember, some information you have been given by the patient may be confidential.
Think carefully and decide whether it is necessary to record it in writing where
anyone may be able to read it; all members of the eye care team, and also the patient
and relatives, have a right to access nursing records.
Mode of handover (Miller, 1998; Sexton et al. 2004):

Different types of tool for nursing handling and taking reports

Tool.1 Currie 2002 Use the 5 P’s……

P1. Patient’s name, age, doctor, past medical history, allergies

P2. Patient’s reason for admission date of admission, days post op

P3. Present restrictions i.e. do Not Resuscitate, Nil By Mouth, Free Fluids, Non Weight
Bearing, Diabetic Diet

P4. Plan of care i.e. the patient’s main problem/need is………………… and he/she will need
the following…… The patient’s next problem/need is……………. & so on

P5. Progress Report must be progressive: Must contain what needs to happen in the next shift

Tool.2 SBAR REPORTING

BEFORE CALLING:

1. Assess the patient

2. Know the admission diagnosis

WARD:
3. Read most recent events / ____________________________________
progress DATE:
____________________________________
4. Have available: Observation TIME OF CALL:
Chart, Fluid Balance Chart, Drug ___________________________ REPORTING
Chart, Latest Laboratory Results, NURSE: _______________________ PERSON
DNR Status CONTACTED: _____________________ TIME
PATIENT REVIEWED: ________________
5. Be sure you are calling
appropriate team / physician

NURSES NOTES
Nursing notes can be sometimes called narrative notes or progress notes but don’t get
confused. The information you write in these pages are for the most part, legal documents.
This sort of documentation is essential for good clinical communication. Appropriate legible
documentation provides an accurate reflection of nursing assessments, changes in conditions,
care provided and pertinent patient information to support the multidisciplinary team to
deliver great care. Documentation provides evidence of care and is an important professional
and medico legal requirement of nursing practice. 

Types of Nursing Notes

There are many types of nursing notes. They almost look similar because they are the
documentation related to same matter. However, they can have different tones which should
be consider while writing or composing any of these nursing notes. They have different
emphasis and choices of word and need of assessment. Think of them in categories. It can
make the work faster and more accurate because you already know which direction need to
go.
Here are some usual scenarios list that are common in any nursing floor.
a. Ongoing progress notes
b. Health notes
c. Incident notes
d. Behavior notes
e. Communication notes
f. Death notes

1. Ongoing documentation notes

 These notes are just routine documentation.
 It is a summary of what is to be done for the patients on regular basis.
 Document what is done as a routine.
 It is just a progress note so anyone can know what is going on with a given patient.
 Chart frequently and every day, in a way is like a diary of the work.
 It is a validation of your work, or rather a history of how the work.

2. Health notes
 This is a type note use when there is some change.
 A change of condition or something we do, like a change of catheter, or an IV
injection.  It is basically, to document an important action to be carried out.
 It is to make sure that the document what is done and what is not done, and why it
is not done.
 Health notes can also include: a. Admission notes b. Discharge notes c. fall notes

3. Incident notes
 These notes are the most important one.
 Incidents can get complicated and filled with critical details.
 It is important that you pay extra attention to time stamping and the order of events
clearly. i.e. date, time, condition and medicine.
 Start writing pocket notes as the events as the unfold.
 Incident notes can be a patient rapidly deteriorating condition; a fire in the room; a
fight between staff.
 These are the type of notes that are most likely to be reviewed in a court of law.
 Make sure you write them with the clear idea and record.

4. Behavior notes
  Behavior notes are similar to incident notes but with some difference.
 Behavior notes are considered as psycho-social notes.
 Be careful while writing these notes.
 Behavior is usually patients having bad behavior, aggressiveness events, attack
events, fights and threats to self or others.
 Patients with behavior issues must be payed close attention because they are
usually the ones who later will get you fired over some blatant lie.
 Record each and every minute you see there is a new patient with behavior issues
 Offer other staff to help you recording these notes carefully.

5. Communication notes
 Communication note are simple notes that are just letting other members of staff
know about some information.
 Somehow, these notes called “over” locally in Pakistan.
 Example: a certain labs has been sent; a patient needs to be ready to be picked up
tomorrow morning at 9.00 am
 Informing other staff of internal tasks.
 By writing these notes, you’ll make sure you don’t get in trouble with your staff.

6. Death notes
 Death notes can be quite simple but also very serious.
 Report the time and manner of death what happened and the time of death, who
you called, when did you call etc.
 In the case of an unexpected death the note will have to write in-depth and long
note.
 Don’t omit any details and time records.
 Document everything did, everything didn’t do and why didn’t do it.
 Get help from supervisor or DON to sit down and write it .
CURRICULUM VITAE
A Curriculum Vitae (also known as a CV) is a written description of a person experience and
qualifications. It is generally used for job opportunities or academia. In most industries the
CV is the first element for candidate screening, generally followed by an interview.

Reasons for Writing a CV Attract attention.

 Create a good impression.
 Show that you have the necessary qualities and qualification to do the job applying
for.

Factors affecting CV
1. The candidate
 Attitudes
 abilities
 Knowledge
 Skills
2. The position
 The scores required to be accepted.
 The skills required to do the job.
 The abilities to cope with a changing and to learn new skills.
 The attitude required to be successful and to be accepted.