JAMIA HAMDARD

RUFAIDA COLLEGE OF NURSING

ASSIGNMENT
TOPIC: NURSING RECORDS AND REPORTS
SUBJECT: NURSING MANAGEMNT
DATE OF SUBMISSION: 27th, FEBRUARY, 2020

Submitted To: Submitted by:

Ms. JAHANARA Ms. VANSHIKA
NURSING TUTOR M.Sc. (N) 2nd YEAR
RCON RCON
ANECDOTAL RECORDS
An anecdotal record is an observation that is written like a short story. They are descriptions
of incidents or events that are important to the person observing. Anecdotal records are short,
objective and as accurate as possible.
Definition
According to Randall, Anecdotal records are a record of some significant item of conduct, a
record of an episode in the life of students, a word picture of the student in action, a word
snapshot at the moment of the incident, any narration of events in which may be significant
about his personality.
Characteristics of anecdotal records
 Anecdotal records must possess certain characteristics as given below-
 They should contain a factual description of what happened, when it happened, and
under what circumstances the behaviour occurred.
 The interpretations and recommended action should be noted separately from the
description.
 Each anecdotal record should contain a record of a single incident.
 The incident recorded should be that is considered to be significant to the student’s
growth and development of example.
 Simple reports of behaviour
 Result of direct observation.
 Accurate and specific
 Gives context of child's behaviour
 Records typical or unusual behaviours
Purposes of anecdotal records
 To furnish the multiplicity of evidence needed for good cumulative record.
 To substitute for vague generalizations about student’s specific exact description of
behaviour.
 To stimulate teachers to look for information i.e. pertinent in helping each student
realize good self- adjustment.
 To understand individual’s basic personality pattern and his reactions in different
situations.
 The teacher is able to understand her pupil in a realistic manner.
 It provides an opportunity for healthy pupil- teacher relationship.
 It can be maintained in the areas of behaviour that cannot be evaluated by other
systematic method.
 Helps the students to improve their behaviour, as it is a direct feedback of an entire
observed incident, the student can analyse his behaviour better.
 Can be used by students for self-appraisal and peer assessment.
Guidelines for making anecdotal record
 Keep a notebook handy to make brief notes to remind you of incidents you wish to
include in the record. Also include the name, time and setting in your notes.
 Write the record as soon as possible after the event. The longer you leave it to write
your anecdotal record, the more subjective and vaguer the observation will become.
 In your anecdotal record identify the time, child, date and setting
 Describe the actions and what was said.
 Include the responses of other people if they relate to the action.
 Describe the event in the sequence that it occurred.
 Record should be complete.
 They should be compiled and filed.
 They should be emphasized as an educational resource.
 The teacher should have practice and training in making observations and writing
records

Items in anecdotal records

 To relate the incident correctly for drawing inferences the following items to be
incorporated.
 The first part of an anecdotal record should be factual, simple and clear.
 Name of the students
 Unit/ ward/ department
 Date and time
 Brief report of what happened.
 The second part of an anecdotal record may include additional comments, analysis
and conclusions based on interpretations and judgments.

Uses of anecdotal records

 Record unusual events, such as accidents.
 Record children's behaviour, skills and interests for planning purposes.
 Record how an individual is progressing in a specific area of development.
 It provides a means of communication between the members of the health care team
and facilitates coordinated planning and continuity of care. It acts as a medium for
data exchange between the health care team.
 Clear, complete, accurate and factual documentation provides a reliable, permanent
record of patient care.
Sample anecdotal record

Child’s name: Ms. Bhoomika

Age: 9 years old
Place: Child Development centre, Jamia Milia Islamia
Date and time: 28th February, 2020, 9:30-10:00am
Observer: Ms. Vanshika
Incident
It was around 9:30am when all the students took out the notebooks from their bags as the
class was about to begin. The special educator distributed a bunch of flashcards with fruits
name on each table. Bhoomika, who engages in group activities otherwise, took all the
flashcards and turned up to me to read them one by one. The other students on the table had
nothing to see. I tried convincing Bhoomika to allow other students to see the flashcards too
but she refused to listen to me. The special educator tried to explain her that it was a group
activity and she has to share the flashcards with other students. Despite repeated attempts, we
couldn’t convince Bhoomika to show the flashcards to other students. She being belonging to
the special child category, could not be dealt harshly. Therefore, I told other students to join
the other table. The other students obeyed and starting learning the fruits name on the other
table. Bhoomika was left alone on the table. Soon after, she took hand of one girl from the
other table and brought her back to read with her. She waved to other students also to come
back to table to learn together.
Comments: Bhoomika, being belonging to the special child category, was presumed to show
certain unexplained behaviour. She has been part of group activities and has rarely indulged
in isolation activities. She initially might have not listened to us, later realising her behaviour
she called back the students to learn with her, which is her normal behaviour.
INCIDENT REPORTS
In a health care facility, such as a hospital, nursing home, or assisted living, an incident
report or accident report is a form that is filled out in order to record details of an unusual
event that occurs at the facility, such as an injury to a patient. The purpose of the incident
report is to document the exact details of the occurrence while they are fresh in the minds of
those who witnessed the event. This information may be useful in the future when dealing
with liability issues stemming from the incident.
Generally, according to health care guidelines, the report must be filled out as soon as
possible following the incident (but after the situation h weas been stabilized). This way, the
details written in the report are as accurate as possible.
Most incident reports that are written involve accidents with patients, such as patient falls.
But most facilities will also document an incident in which a staff member or visitor is
injured.
Definition
An incident report is an electronic or paper document that provides a detailed, written
account of the chain of events leading up to and following an unforeseen circumstance in a
healthcare setting. The incident doesn’t have to have caused harm to a patient, employee, or
visitor, but it’s classified as an “incident” because it threatens patient safety.
To ensure the details are as accurate as possible, incident reports should be completed within
24 hours by whomever witnessed the incident. If the incident wasn’t observed (e.g., a patient
slipped, fell, and got up on his own), then the first person who was notified should submit it.
For the most part, these incident reports are completed by nurses or other licensed personnel
and are used for risk management, quality assurance, educational, and legal purposes.
In the event that an incident involves a patient, the patient will often be monitored for a
period of time following the incident (for it may happen again), which may include
taking vital signs regularly.
Incident reports comprise two aspects. First, there is the actual reporting of any particular
incident (this may be something affecting you, your patient or other staff members), and the
relevant corrective action taken. Secondly, information from incident reports is analysed to
identify overall improvements in the workplace or service.
Purpose of an Incident Report
Incident reports are used to communicate important safety information to hospital
administrators and keep them updated on aspects of patient care for the following purposes:
1. Risk management. Incident report data is used to identify and eliminate potential risks
necessary to prevent future mistakes. For example, if an incident report review finds that
most medical errors occur during shift changes, risk management teams may suggest
that nursing staff develop standardized turnover protocols to avoid future errors.
 2. Quality assurance. Quality assurance is all about patient safety, customer satisfaction,
and improving healthcare quality. Quality control groups comb through incident reports
to look for indicators that suggest a patient received high-quality, patient-centered care
at a reasonable price.
3. Educational tools. Incident reports make great training tools because everyone has an
innate ability to learn from their mistakes — or the mistakes of others. Healthcare teams
often use resolved incident reports as educational tools to prevent similar occurrences.

Contents of an incident report

 The name of the person(s) affected and the names of any witnesses to an incident
 Where and when the incident occurred
 The events surrounding the incident
 Whether an injury occurred as a direct result of the incident
 The response and corrective measures that were taken
 It should be signed and dated prior to handing it in to the appropriate person, such as a
supervisor

Situations Should be Reported

Examples include:
 Injuries – physical such as falls and needle sticks, or mental such as verbal abuse
 Errors in patient care and medication errors
 Patient complaints, any episodes of aggression
 Faulty equipment or product failure (such as running out of oxygen)
 Any incident in which patient or staff safety is compromised
Important points:
 Use objective language
 Write what was witnessed and avoid assigning blame; write only what you witnessed
and do not make assumptions about what occurred
 Have the affected person or witnesses tell you what happened and use direct
quotations
 Ensure that the person who witnessed the event writes the report
 Report in a timely manner
 Complete your report as soon as the incident occurs, or as soon as is feasible
afterwards.
 Never try to cover up or hide a mistake.
Prevention of incidents
 Assess clients for allergies and intervene as needed (e.g., food, latex, environmental
allergies)
 Determine client/staff member knowledge of safety procedures
  Identify factors that influence accident/injury prevention (e.g., age, developmental
stage, lifestyle, mental status)
 Identify deficits that may impede client safety (e.g., visual, hearing,
sensory/perceptual)
 Identify and verify prescriptions for treatments that may contribute to an accident or
injury (does not include medication)
 Identify and facilitate correct use of infant and child car seats
 Provide the client with appropriate method to signal staff members
 Protect the client from injury (e.g., falls, electrical hazards)
 Review necessary modifications with client to reduce stress on specific muscle or
skeletal groups (e.g., frequent changing of position, routine stretching of the
shoulders, neck, arms, hands, fingers)
 Implement seizure precautions for at-risk clients
 Make appropriate room assignments for cognitively impaired clients
 Ensure proper identification of client when providing care
 Verify appropriateness and/or accuracy of a treatment order

Sample incident report

Name of the patient: Ms. X

Name of the concerned staff: Ms. T
Date of incident: 29th Feb, 2020
Time of incident: 2:30 am
Ward: female psychiatry ward
Description of the incident: Ms. X, 57-year-old patient admitted in female psychiatry ward on
27th February with diagnosis of major depressive episode with chronic insomnia under Dr. Y.
the patient was on antidepressant and sedatives from 7 years. The patient’ vitals were
checked at 10 pm and later the patient was administered the night dose of antidepressant and
sedative. The patient was asleep at 11:30 pm when the concerned staff went to see her. Later
at 2:30am the relative of the neighbour patient came running to the nursing station and told
that Ms. X has fallen from the bed and her head is bleeding. The staff rushed to the spot and
saw Mx. X lying on the floor with bruise on the forehead. The staff put her back to bed and
informed the doctor on duty. The bed side rails were not put and thus, the patient under
sedation fell from the bed. The doctor on duty along with staff took patient to dressing room.
A bruise of 2.5x1cm was identified on the forehead with active bleeding. The doctor stitched
the site with 2 stitches and put the dressing. The patient was later shifted to bed and vitals
were recorded. The incident form was filled and attached to patient file. The incident was
reported to nursing authorities as well concerned doctor in the morning rounds.
Action taken: The concerned nurse was informed to write an explanation letter along with the
filling of the incident form.
Follow-up action: it is mandatory for staff to give complete information about the current as
well as previous treatment regime of the patient. The staff must know the action of the
particular drug and take necessary safety measures. The nurse must take intermittent rounds
in wards at night to ensure patients are safe and asleep.
DAY AND NIGHT REPORT
A day or night report is a written report where the information is used by several health
professionals to carry out health related activities of a client. It is a clinical, scientific, and
administrative and legal document related to nursing care given to the individual, family and
community.
Purposes
 Supply data that are essential for programme planning and evaluation.
 Provide the practitioner with data required for the application of professional services
for the improvement of family's health.
 Tools of communication between health workers, the family & other development
personnel Effective health records show the health problem in the family and other
factors that affect health.
 Indicates plans for future.
 Help in the research for improvement of nursing care.

Principles
 Nurses should develop their own method of expression and form in record
writing.
 Written clearly, appropriately and adequately.
 Contain facts based on observation, conversation and action.
 Select relevant facts and the recording should be neat, complete and uniform
 Valuable legal documents and so it should be handled carefully, and accounted
for.
 Records should be written immediately after an interview.
 Records are confidential documents.
 Accurately dated, timed and signed
 Not include abbreviations, jargon, meaningless phrases

Importance
 Reports should be made promptly if they are to serve their purpose well.
 A good report is clear, complete, concise.
 If it is written all pertinent, identifying data are include – the date and time, the people
concerned, the situation, the signature of the person making the report.
 It is clearly stated and well organized for easy understanding.
 No extraneous material is included.
 Good oral reports are clearly expressed and presented in an interesting manner.
  Important points are emphasized.

Nurse’s responsibility:
 patient has a right to inspect and copy the record after being discharged
 Failure to record significant patient information on the medical record makes a nurse
guilty of negligence.
 Medical record must be accurate to provide a sound basis for care planning.
 Errors in nursing charting must be corrected promptly in a manner that leaves no doubts
about the facts.
 In reporting information about criminal acts obtained during patient care, the nurse must
reveal such information only to the police, because it is considered a privileged
communication.
 FACT Information about clients and their care must be functional. A record should
contain descriptive, objective information about what a nurse sees, hears, feels and
smells.
 ACCURACY A client record must be reliable. Information must be accurate so that
health team members have confidence in it.
 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.
 CURRENTNESS Delays in recording or reporting can result in serious omissions and
untimely delays for medical care or action legally, a late entry in a chart may be
interpreted on negligence.
 ORGANIZATION The nurse or nurse manager communicates information in a logical
format or order. Health team members understand information better when it is given in
the order in which it is occurred.
 CONFIDENTIALITY Nurses are legally and ethically obligated to keen information
about client’s illnesses and treatments confidential.

THE PACE FORMAT

This format involves a straightforward organizational technique. PACE is an acronym
standing for Patient, Actions, Changes and Evaluation, all of which serve as sections in the
report.
•   Patient: List all of the patient’s personal information, including age, medical history
details, current condition and latest symptoms.
•   Actions: Include a step-by-step account of the facility’s treatment plan.
•   Changes: Detail the patient’s ongoing needs and list all actions the incoming nurse should
take during his or her shift.
•   Evaluation: Provide notes on the patient’s reaction to treatment, along with any other
important observations you make during your shift.

Day/night report sample

Mr. X, 40-year-old male, admitted in male medicine ward on 25th Feb, 2020 under Dr. M
with diagnosis of Uncontrolled Diabetes mellitus with unhealed ulcer on the left foot. The
patient has been a known case of DM from 15 years and has been on on-off treatment since
then. The patient is also a known case of hypertension for 20 years with on-off treatment. The
patient’ RBS is 323 mg/dl. The patient’ latest symptoms are polyuria, polydipsia and
polyphagia. The patient has uncontrolled blood sugar level. The patient is currently on insulin
8 units S/C TDS and oral glimulin 2mg BD with regular blood sugar monitoring. The patient
currently complains of frequent urination and thirst. The nurse maintains strict intake- output
and weight monitoring. The patient is administered insulin and drugs on time to maintain the
blood sugar levels. The patient currently urinates 5-6 times a day with RBS of 230 mg/dl.
Vitals recorded and are normal. Patient slept at 11:30 pm comfortably along with night dose
of drugs. Patient hand over given to morning shift staff.

NURSE’ S NOTES

A nursing note is a medical note into a medical or health record made by a nurse that can
provide an accurate reflection of nursing assessments, changes in patient conditions, care
provided and relevant information to support the clinical team to deliver excellent care.
Complete and accurate nursing notes are crucial to make good decisions for patient care.
Nursing notes should provide a clear and accurate picture of the patient while under the care
of the healthcare team. Federal, state, and institutional regulations require that nursing notes
follow broad guidelines to determine if a nurse’s action was reasonable and prudent.

Contents of nurse’s notes

In addition, to the type of information found on the medical note page, nursing notes should
follow these guidelines:
 Always include interventions initiated and the patient response when documenting an
acute abnormality found during assessment
 Always elaborate when documenting a body system abnormality with each
assessment
 Always include if an assessment was visual, audible, and/or tactile
 Reconcile mismatched objective and subjective assessment findings
 Document the patient’s baseline mental status
 Always assess the patient at the time of discharge or transfer.
 Use quantifiable data with descriptions. Reference to common objects, such as a
quarter or soda can, to describe the size or shape of wounds may be useful with
awkward shapes or when there isn’t access to a measurement device.

Importance of nurse’ notes

Nursing notes can be used for various purposes from assessing proper medical care to
malpractice litigation. Thus, it is important that nurses write their nursing notes with various
audiences in mind:
 The Healthcare Team: Nursing notes provide a healthcare team a complete and
accurate timeline of a patient’s health status and care. This is key to determining a
diagnosis and further care.
  The Nurse: Nursing notes should be complete enough to jog a nurse’s memory if any
details are not clear or hazy. In the unfortunate case that a nurse must testify for a
lawsuit, clear and accurate nursing notes serve to ensure the details of a nurse’s care.
 The Lawyers, Judge, and Jury: Clear, comprehensive nursing notes ensure if our
judicial system can determine if a patient’s nursing care was reasonable and prudent.

Guidelines When You Write Notes on Any Patient:

 Always use a consistent format: Make a point of starting each record with patient
identification information. Each entry should also include your full name, the date and the
time of the report.
 Keep notes timely: Write your notes within 24 hours after supervising the patient's care.
Writing down your observations and noting care given must be done while it is fresh in
your memory, so no faulty information is passed along.
 Use standard abbreviations: Write out complete terms whenever possible. If you must
use an abbreviation, stick to standard medical abbreviations familiar to other nurses or the
attending physician.
 Remain objective: Write down only what you see and hear. Avoid noting subjective
comments or giving your own interpretation on the patient's condition.
 Note all communication: Jot down everything important you hear regarding a patient's
health during conversations with family members, doctors and other nurses. This will
ensure all available information on the patient has been charted. Always designate
communication with quotation marks.
 Ignore trivial information: Everything included in your nurse’s notes should directly
relate to your patient's health. Do not note information on your chart that does not pertain
to their immediate care.
 Keep it simple: Notes are not meant to be a work of art. They are designed to be quickly
read, so nurses and doctors on the next shift can be caught up to speed on a patient. Focus
only on specific information relevant to symptoms you are charting. Do not go into depth
on the patient's medical history.
 Write clearly: When you do handwritten notes, make an effort to keep your handwriting
clear and readable. Illegible handwriting can lead to a patient receiving the wrong
medication or an incorrect dosage of the right medication. This can have serious, or even
fatal, consequences.
 Standard nurses note usually include an opening note, middle notes and a closing note. In
these notes, you should note any primary or secondary problems a patient is experiencing.
Record things like blood pressure, heart rate and skin colour that can offer insight into
these issues.
 Make a record of any assessments you have administered during your shift. Indicate if
more tests are needed and include a probable diagnosis of their condition.
 Always note what medications the patient has been prescribed.
 List all medications the patient has been given, along with dosage and how the medicine
was administered.

Nurse’ notes Sample

Mr. C alert, awake and oriented to person and situation but is confused to time and place. He
is able to state his name. vitals recorded and are normal. Patient currently on intermittent
oxygen through simple face mask @2l/min. Intake output charting done. Morning dose of
medications administered. FBS charting done and informed to unit doctor. Nebulisation with
levolin done at 11 am. Chest x-ray done, report due. ECG recorded in morning shift and
attached to file. Patient allowed orally, took lunch and slept comfortably.

HANDING OVER NOTES

A nursing handover occurs when one nurse hands over the responsibility of care for a patient
to another nurse, for example, at the end of a nursing shift. On average, nursing handovers
occur three times a day for each patient.
Clinical Handover
Group Handover (inpatient, ward based)
 Occurs every day at the time of the shift change-over or start of shift
 Takes place in a designated area 
 All nurses, including student nurses, commencing a shift attend the group handover 
 Group handovers are led by the AUM in charge of the shift 
 ISBAR format applied to structure handover (EMR handover report function may be
useful) 
 Handover is respected with minimal disruptions (no mobile phones or pagers to be
answered)
 At the conclusion of group handover, any important messages pertaining to the ward or
hospital are discussed e.g. staffing, potential issues relevant to running of the unit
 Group handover is completed allowing adequate time for bedside handover before nurses
finish the previous shift
 Handover for nurses working in the community allows adequate time to review all
documented handovers

Bedside Handover (inpatient, ward based)

 Handover occurs by each patients’ bedside including patients, parents/ carers 
 Handover occurs between the nurse that holds responsibility for care and the nurse who
will be assuming responsibility for the care of the patient
 Positive Patient identification process occurs during bedside handover confirming full
name, date of birth and Medical Record Number (MRN) to the EMR as per the RCH
Patient Identification Procedure
 Clinical alerts are identified (e.g. FYI flags, allergies, infection control precautions) 
 ISBAR format is applied to structure handover 
 Patients and parents/ carers are encouraged to participate in bedside handover and be
aware of the plan of care for the next shift
 Patients, parents/ carers and nurses are encouraged to utilise the communication boards in
the patient room as a tool for handover between the multidisciplinary team 
 The handover is documented within EMR  
 Following handover at the bedside, an EMR review takes place
 In specified clinical areas (e.g. Wallaby & Pre-op Hold) direct patient care handover may
only occur in electronic documentation within the EMR 

Break Handover (inpatient, ward based)

 Handover occurs between the nurse that holds responsibility for care and the nurse who
will be assuming responsibility for the care of the patient
 ISBAR format is utilised to structure handover focusing on ISR – identification of the
patient, current situation and any risks or recommendations for break interval 
 The handover is documented in the EMR 

Transfer of patient within the hospital (for procedure, treatment or to another ward)
 All patients transferred to from one clinical area to another clinical area require handover
to be documented in the EMR. This includes details of the transfer time indicating a
transfer of professional responsibility and accountability
 Positive Patient identification process occurs to confirm full name, date of birth and
Medical Record Number (MRN) to the EMR as per the RCH Patient Identification
Procedure
 Clinical alerts are identified (e.g. FYI flags, allergies, infection control precautions, MET
modifications) 
 The handover is documented in the EMR 
 A patient can be transported by CARPs, parents/ carers if the patient is assessed as:

o Stable
o Predictable 
o Having no fluids or blood product transfusions running
o Requiring clinical observations <4 hourly
o Handover can be conducted over the phone to the receiving nurse/ AUM/
appropriate health practitioner who will then assume responsibility and
accountability for the patient 
 A patient must be escorted by the nurse if the patient is assessed as:
o Unstable
o Having fluids or blood transfusions running
o Requiring clinical observations <4 hourly
o Handover occurs between the nurse that holds responsibility for care and the nurse
who will be assuming responsibility for the care of the patient
 Inpatients to theatre
Handover occurs between the nurse that holds responsibility for care and the pre-
op hold nurse who will be assuming responsibility for the care of the patient
  Ambulatory Care patient to another clinical area
The nurse transferring care contacts the relevant AUM of the receiving clinical
area to ensure patient is expected and handover is given. Relevant local
administrator (Desk Staff, Ward Clerk) to be notified of transfer or admission by
the AUM
Non-Clinical Activities
 Parents, carers, teachers, volunteers etc. can escort a patient off the ward if they have
been assessed as safe to leave the ward without a nurse as per the Supervision and
movement of inpatients across RCH and access to inpatient areas procedure
 If the patient is deemed safe without a nursing escort document in the EMR

Patient Discharge
 On discharge home patients are provided with written discharge advice about the patient’s
hospital stay
 An After-Visit Summary (AVS) can be printed for the parents/ carers, along with any
attendance certificates, which has a minimum data set including: name of consultant,
diagnosis, medication plan, follow up information and phone number to contact if more
information required 
 The clinician documents in the EMR that the discharge advice has been given
to the parents/ carers and the time of discharge. 
Companion documents 
 Policy and Procedures
o Patient and Family centred Care (procedure)
o Governance (policy)
o Consumer Focused Care (policy)
o Patient Identification (procedure)
o Clinical Handover (procedure)
o Infection Prevention and Control and Disease Outbreak (policy)
o Supervision and movement of inpatients across RCH and access to inpatient
areas Procedure Transmission based precautions (procedure)
o Multi resistant organisms (procedure)

There are four main styles of handover reported in the literature

• Verbal handover
• Tape recorded handover
• Bedside handover
• Written handover

An effective handover in nursing brings numerous benefits, such as:

 Keeping patients’ care progressing smoothly.
 Making patients feel calmer and more confident in your healthcare service.
 Reducing the need for service users to repeat themselves.
 Helping to maintain records of a patient’s progress.
 Helping staff to deliver more consistent care.
 Allowing staff to communicate issues and concerns, so the next person can address
them swiftly.
 Promoting person-centred care.
 Saving staff time and energy, which helps to prevent stress and minimise mistakes.
 Helping staff feel more prepared and confident to do their job.
 Promoting a culture of teamwork and support in your care setting

Nursing handover notes example

Patient Mr. G handover given to the evening shift staff. Patient file and records handed over
to the concerned staff. Patient vitals recorded and reported. Nurses notes of the shift
completed and discussed. Morning dose of medication given. Evening dose due. 2 hourly
RBS charting to be done. Intake output monitored in morning shift and recorded. Patient to
be sent for USG whole abdomen at 4pm after information to concerned doctor. Medicine
reference due post collection of USG report. CBC, KFT, LFT samples send to lab, reports
due in evening. Patient to be monitored for drowsiness. Fluid NS 60ml/hr on flow until
further orders. Discharge planned after medicine clearance.

CURRICULUM VITAE
A curriculum vita is a compilation of one’s education, employment experience, and scholarly
works.
A nursing CV is the equivalent of a nursing resume. It’s application document that outlines
your skills, work experience, and education to allow employers to see that one has the
required credentials and licenses to perform the duties of a nurse.
Standard CV format guides hiring managers through your CV effectively. It starts with a
summary statement to hook their attention, and then leads them quickly through your skills
section into your experience information, which describes your previous jobs in great detail.
Your CV should then close with a brief education section.
Curriculum Vitae Information to Include:
Contact Information
 Name
  Address
 Telephone
 Cell Phone
 Email
Education
Include dates, majors, and details of degrees, training, and certification
 University
 Graduate School
 Doctoral Education
 Post-Doctoral Training
Employment History List in chronological order, most recent first and include position
dates
 Work History
 Research (if any)
Professional Qualifications
 Certifications and Accreditations
 Computer Skills
 List courses taught/ developed and where
 Awards, Presentations (Indicate if peer reviewed, and whether a poster or podium
presentation), Publications, Books, Professional Memberships, Committee
Participation, Interests

Vital skills for nursing CV

Although every nursing role will be different, there are certain skills that are essential to
nurses across the board.
1. Patient care – The ability to care for patients is paramount to a nurse’s skill set and
should be evident throughout the CV.
2. Knowledge of medication- Administering medications and understanding their effects
is another crucial skill for most nurses.
3. Ward management – Not only is this skill useful if you plan on climbing the ranks
within a ward, but it will also show that you know how a ward is run, and have a
deeper insight into staffing levels and patient bed allocation charts.
4. Hygiene and health - Ensuring you know what your patient’s area eating, and that
they are clean and comfortable in their beds
DOs:
 Maintain plenty of white space (in the margins, between listings, etc.)
 Using large enough type font to make it easy to read
 Preserve order by labelling each page with your name and the page number
 Organize content by providing clear explanations and intuitive listings/sections
 Proofread information to catch errors
 If longer than one page, include name and page number on each page after the first
DON’Ts:
 Don’t have any typos due to spelling or grammatical errors
 Don’t rely on your computer program’s spell check function; it won’t detect when
you’ve substituted the wrong word (e.g. effect vs. affect)
 Don’t ignore aesthetics: Don’t skimp on space by cramming your content together,
minimizing margins or lumping separate ideas into lengthy paragraphs; emphasize
independent points with separations so that your CV will be easy to read
 Don’t include private personal information such as age, ethnicity, political affiliation,
religion, social security number, marital status, place of birth, height, sexual
orientation, weight or health information
 Don’t rely on a template
Example of Curriculum vitae
Ms. A, Nursing Tutor
Location: Noida
Phone no: 8755674422
Email: XXXXXXXXXXXXXXXXX

Career Objective
Looking for a challenging position in a hospital where my profound medical professional and
practical experience will be fully utilized.
Career Summary
 A patient oriented and caring professional with excellent patience and remarkable
organizing skills possesses 2 years’ experience as a Nurse.
 Proved loyalty and knowledge of medical ethics.
 Proven record of reliability and responsibility.
 Possess special sensitivity to meeting different needs in varied situations.
 Establish contacts with patients, family, staff and physicians.
Personal Qualities
  Remain calm and professional throughout critical incidents.
 Excellent in communication skills in written and verbal both.
 Resourceful problem solver capable of implementing solutions to complex problems.
 Ability to work in pressure situations.
Responsibilities Handled
 Caring the patient 24 X 7.
 Manage the admission and discharging of patients.
 Interacting with the medical bodies in the hospital.
 Provide suggestions to family member and other staff on diseases.
 Provide assistance to Nursing Manager in the supervision of staff nurses.
 Maintain the patient charts.
 Provide training to the new recruiters.
Technical Experience
 Proficient in all apparatus and equipment of operation theater.
 Proficient in basic use of computer.
Achievements
 Provide excellent support in operation theatre.
 Patient care up to 15 patients per section.
 Receive many appreciations and awards for excellent work.
Employer
 Working as Nurse in ASD Hospital from 2010 - Present.

OFFICIAL LETTER
An official letter is one written in a formal and ceremonious language and follows a certain
stipulated format. Such letters are written for official purposes to authorities, dignitaries,
colleagues, seniors, etc and not to personal contacts.
An official letter should have the following:
Sender’s Address
The sender’s address is usually put on the top right-hand corner of the page. The address
should be complete and accurate in case the recipient of the letter wishes to get in touch with
the sender for further communication.
Date
The sender’s address is followed by the date just below it, i.e. on the right side of the page.
This is the date on which the letter is being written. It is important in formal letters as they are
often kept on record.
Receiver’s Address
After leaving some space we print the receiver’s address on the left side of the page. Whether
to write “To” above the address depends on the writer’s preference. Make sure you write the
official title/name/position etc of the receiver, as the first line of the address.
Greeting
This is where you greet the person you are addressing the letter to. Bear in mind that it is a
formal letter, so the greeting must be respectful and not too personal. The general greetings
used in formal letters are “Sir” or “Madam”. If you know the name of the person
the salutation may also be “Mr. XYZ” or “Ms. ABC”. But remember you cannot address
them only by their first name. It must be the full name or only their last name.
Subject
After the salutation/greeting comes the subject of the letter. In the centre of the line write
‘Subject” followed by a colon. Then we sum up the purpose of writing the letter in one line.
This helps the receiver focus on the subject of the letter in one glance.
Body of the Letter
This is the main content of the letter. It is either divided into three paras or two paras if the
letter is briefer. The purpose of the letter should be made clear in the first paragraph itself.
The tone of the content should be formal. Do not use any flowery language. Another point to
keep in mind is that the letter should be concise and to the point. And always be respectful
and considerate in your language, no matter the subject of your letter.
Closing the Letter
At the end of your letter, we write a complimentary losing. The words “Yours Faithfully” or
“Yours Sincerely” are printed on the right side of the paper. Generally, we use the later if the
writer knows the name of the person.
Signature
Here finally you sign your name. And then write your name in block letters beneath
the signature. This is how the recipient will know who is sending the letter.

Example of an official letter

From,
Ms. X
Ward In charge
Medicine ward
HAHC hospital, JH

Date: 29th Feb, 2020

To,
The Assistant Nursing superintendent
HAHC Hospital
Jamia Hamdard
Delhi

Subject: For issue of new ECG machine for the male medicine ward.
Respected madam,
This is to bring it to your kind notice that the ECG machine of male medicine ward is not
working properly. It has been repaired several times but it tends to give same ECG report for
all patients. We have been using the ECG machine of pulmonary ward in times of need.
There are several patients in ward who require ECG monitoring 2 hourly. It is inconvenient
for staff to get the machine from pulmonary ward every time. Since both wards have sick
patients, care cannot be compromised. It is a vital instrument for the ward.
Kindly issue us a new ECG machine as soon as possible for effective patient care.
Thanking you
Yours sincerely
Ms. X
Ward in charge
Medicine ward

References:
1. Hynes, J. (2009). Charting check-up: Don’t be intimidated by incident reports.
LPN2009 March/April 2009 Volume 5 Number 2.T
2.  http://www.medicine.ox.ac.uk/bandolier/booth/Risk/accidents.html
3. Vincent C.A. Presentation at BMJ conference ‘Reducing Error in Medicine;’. London.
March 2000
4. NHS Department of Health Report. An Organisation with a Memory. 2000. P49
5. NHS Department of Health Report. An Organisation with a Memory. 2000.
6. National Safety and Quality in Healthcare Service Standard 6 – Communicating for
Safety Standard. ACSQHC, 2019. (Accessed 16 May
2019 https://nationalstandards.safetyandquality.gov.au/topic/user-guide-acute-and-
community-health-service-organisations-provide-care-children/communicating)
7. National Safety and Quality in Healthcare Service Standard 3 - Preventing and
Controlling Healthcare-Associated Infections. ACSQHC, 2019 (Accessed 16 May
November https://nationalstandards.safetyandquality.gov.au/3.-preventing-and-
controlling-healthcare-associated-infection)