records,reports,discipline

8/4/2019 records,reports,discipline

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RECORDS ANDREPORTSBy: Ann Grethel R. Tan, RN


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Reports are oral or written exchanges ofinformation shared between caregivers orworkers in a number of ways. A report

summarizes the services of the person,personnel and of the agency. Reports arewritten usually daily, weekly, monthly oryearly.


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A "paperless" patient record has special riskmanagement issues that need to be considered. Manyorganizations are making the transition to a "paperless"patient record. Although the basic principles fordocumentation remain the same in a paperless system,maintaining the patient's right to privacy becomes agreater challenge. The first major guideline that must beestablished is the design of specific criteria for who can

access patient information. Then, guidelines on theactual process of accessing patient information must beestablished..


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In response to the demand for objectivemeasures of quality, a number of healthplans, healthcare providers, employerpurchasing groups, consumer informationorganizations and state governments havebegun to formulate healthcare quality

report cards.


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In point of facts, the scores that apply to specificproviders may diverge significantly from planwide scores (Grimaldi). In addition some criticsof healthcare report cards point out that health

plans may receive conflicting ratings on differentreport cards. This is result of using differentperformance measures and how each reportcard chooses to pool and evaluate individual

factors.


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It is to be written jointly by the managerand staff nurse. It should be reliable, validand accurate, showing progress made bythe nurse giving illustrations tosubstantiate value judgments. Anyimprovements are to be noted, and staff

nurses should know exactly where theystand.


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Most facilities use an incident reporting systemto document accidents and errors. Incidentreports are an integral part of a risk management

program and help risk managers track conditionsthat might need to be corrected. Incident reportscan help those in staff development identifyeducation and training needs. Incident reports

assist nurse managers in tracking andmaintaining staff competencies.


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Nurses should know what must be reported,

complete the incident report in its entirety, beobjective in reporting, include names ofwitnesses to the incident preserving theconfidentiality of witness patients by using the

patient's admission number, submit theincident report through proper channels,never refer to incident reports in a patient'srecord as the privilege of confidentiality can

be waived, consult with nurse manager or theinstitution's risk manager when questionsarise.


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Permanent, cumulative evaluationrecords can be used to assess howthe nurse can best be used in the

agency. They can be used as abasis for pay increases andpromotions or termination.


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In the past, discipline meant rigid obedience torules and regulations, the violation of which

resulted in punitive actions. Today, discipline is regarded as a constructive and

effective means by which employees takepersonal responsibility for their own performanceand behavior.

Discipline is defined as influencing behaviorthrough reprimand.

Progressive discipline ties reprimand to theseverity and frequency of the employeesinfractions.

Positive discipline tries to involve people morepositively and directly in making decisions toimprove their behavior.


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1. A strong commitment to the vision,philosophy, goals, and objectives of theinstitution.

2. Laws that govern the practice of allprofessionals and their respective Codes ofConduct.

3. Understanding the rules and regulations ofthe agency.

4. An atmosphere of mutual trust andconfidence.5. Pressure from peers and organization.


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A sound disciplinary program must be tailored tothe objectives of the institution. This shouldinclude a set of disciplinary policies andprocedures, a uniform application of discipline

rules, a disciplinary committee, and an orientationprogram for all new employees whereexpectations of appropriate performance andbehavior are emphasized. There must be

continuous communication to all employeesregarding changes in personnel and disciplinepolicies. Changes must be communicated beforethese are affected.


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Have a Positive Attitude

The managers attitude is very important in preventing

or correcting undesirable behavior. If personnel aretreated as suspect, they are now likely to provide thetrouble that the manager anticipates. People tend todo what is expected of them, therefore it is themanagers duty to maintain a positive attitude by

expecting the best from the staff.


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Investigate Carefully

The ramifications of disciplinary action are so

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


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Be Prompt

Managers should not be so expeditious that theyneglect to be thorough in ascertaining the facts. If

a staff nurse is disciplined unfairly orunnecessarily, the effects on the entire staff maybe severe. However, if the discipline is delayed,the relationship between the punishment and the

offense may become less clear.


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Protect Privacy

Disciplinary action affects the ego of the staff

nurse. Thus it is better to discuss the situation inprivate.


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Focus on the Act

When disciplining a staff nurse, the manager

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


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Enforce Rules Consistently

Offending employees should be treated equally or

consistently for similar transgression. Equaltreatment is based on rules with specific penaltiesfor various acts and the number of offenses.


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Be Flexible

Consistent implementation is complicated by the

fact that individuals and circumstances are neverthe same. A penalty should be determined onlyafter the entire record of the employee isreviewed.


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Advise the Employee

The employees must be informed that their

conduct is not acceptable.


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Take Corrective, Constructive Approach

The manager should be sure that the staff nurse

understand that the behavior was contrary to theorganizations requirements and should explainwhy such regulations are necessary. The staffshould be counseled as to what behavior is

required and how to prevent future disciplinaryaction.


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Follow Up

The manager should quietly investigate to

determine whether the staff behavior haschanged.


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An employee charged for breach of the rules andregulations, policies, norms of conduct shall begiven due process. There must be existing rules of

conduct governing his behavior and adocumentation of actual violation of such rulemust support charges. The employee chargedmust be notified in writing about the violation andgiven the right to counsel.

Disciplinary action should be progressive in naturesuch as counseling and oral warning, writtenwarning, suspension, and dismissal.


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Counseling and oral warning are best given in privateand in an informal atmosphere. The employee is givena fair chance to air his side. The relevant facts areanalyzed and evaluated against his past performance.

The employee is then counseled regardingexpectations of improves behavior/ performance, waysof correcting the problem and a warning that arepetition of the same offense may warrant further

disciplinary action. The employee must commit tocorrect the behavior. He should be informed of anyfollow up action that may be taken.


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It is preceded by an interview similar to the oralwarning. The employee must be told after theinterview 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, theemployees commitment to take corrective action,

and any follow up action to be taken.


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Suspension over minor violation is givenafter an evidence of oral and writtenwarnings. Although a violation is a major

infraction, suspension, rather thandismissal is applied when managementfeels that the employee can still berehabilitated. Accurate documentation of

oral and written warnings includingsuspension, if done, are necessaryevidences of due process.


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Dismissal is invoked only when all otherdisciplinary efforts have failed. The Disciplinarycommittee should be very sure that the cause for

dismissal conforms with the criteria of a majordiscipline violation is contained in the policymanual, and for government employees, thosecontained in the Civil Service Rules andRegulations and the codes of conducts. A reviewis done by higher management.


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