NURSING MANAGEMENT

ASSIGNMENT
ON
ANECDOTAL RECORD
FOR STAFF NURSE

SUBMITTED TO

SUBMITTED BY

M.Sc ( N ) – II year

GCON -Cuddalore

SUBMITTED ON:
 ANECDOTAL RECORD

INTRODUCTION:

Anecdotal records are factual description of the meaningful incidents and

events that the teacher has observed in the pupils lives. Each incident should be
written down shortly after it happens. The description may be recorded on
separate cards or as running accounts, one for each pupil, on separate pages in a
notebook.

DEFINITION:

‘Anectodes’ are factual records of an observation of a single, specific,

significant incident in the behaviour of a student or a verbal snapshot of an
incident. It may also be referred as a simple statement of an incident deemed by
the observer to be significant with respect to a given pupil.

CHARACTERISTICS OF ANECDOTAL RECORD:

Simple reports of behaviour : A factual description of an event, how it

occurred; what happened; when it occurred and under what circumstances the
behaviour occurred will be described by the observer i.e., objective description
of pupil’s behaviour recorded from time to time, along with observer’s
comments and the treatment

Gives context of the child’s behaviour :

 The incident record should be, that is considered to be significant to the

pupil’s growth and development.
 Each anecdotal record should contain a record of a single incident.
  The incident recorded should be one i.e., considered to be significant to
the pupil’s growth and development. Inferences, assumptions or guesses
must be avoided unless it signifies.
 The record should be regarded as confidential. It should not fall into
irresponsible hands.

WHEN WRITING AN ANECDOTE:

 Observe the incident

 Identify if the incident is valuable (ie. developmentally significant).
 Complete the process by writing it down after it has occurred.
 The account is transcribed from memory; it preserves an important
developmental moment and provides a permanent record of a child’s
growth and trends [or individual’s growth, behaviour, etc].
 Anecdotal records are most reliable if jotted down as soon as possible
after the event, when things are still clear in your memory. [When you are
a teacher on the floor this is not always possible to use key words to help
jog your memory later.]
 Interpretation or developmental significance notation is written up
separately from the observation.

PURPOSES OF ANECDOTE:

 To furnish the multiplicity of evidence needed for good cumulative

record.
 To substitute for vague generalizations about students specific 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 methods.
 Helps the students to improve their behaviour, as it is a direct feedback of
an entire observed incident, the student can analyse his/her behaviour
better.
 Useful in supplementing valid observations made by other means.
 Can be used by students for self-appraisal and peer assessment.

HOW TO USE ANECDOTAL RECORDS EFFECTIVELY ???

 Criteria for observation of student nurse are:

 Initiative and skill in recognizing and meeting patient’s needs (Physical,
emotional, spiritual, social)
 Ability to make nursing assessment in the clinical setup.
 Initiative in planning nursing care to the patients.
 Precautionary measures used to safe guard the patients and personnel.
 Maintaining patient-nursing relationship
 Initiative in assuming professional responsibility
 Accuracy and judgement in carrying out medical prescriptions.
 Effort in self-development by using self-evaluation techniques.
ITEMS IN ANECDOTAL RECORD:

To relate the incident correctly for drawing inferences, the following items
should incorporated:

 Name of student, class and school, date of observation.

 Setting background of the incident.
 Signature of the observer.
 Interpretation of the behaviour.
 Recommendations concerning the behaviour.

PARTS OF ANECDOTAL RECORD:

The first part of an anecdotal record should be factual, simple, and clear.

 Name of the students

 Unit/ward/department
 Date and time of the observation
 Brief and accurate report of what exactly happened.

The second part of the anecdotal record may include additional comments,
analysis and conclusions based on interpretations and judgements.

 The first part of answers:

 Who was involved
 Where did it take place
 When did it occur
 What happened.

WELL WRITTEN ANECDOTAL RECORDS INCLUDES:

  A brief description to build a visual image of the setting
 Summarization of how the incident happened
 Description of words to tell what was said (quotes)
 Factual and nonjudgmental facts (journalistic approach)
 Direct quotes and descriptions of the child’s expressions and gestures are
important to include because they provide
 Valuable information for review.
 Description of what was said and observed in a nonjudgmental and in a
Non-interpretive manner

SUGGESTIONS FOR TEACHERS FOR WRITING ANECDOTAL

RECORD:

 Records should be complete. There are several different styles of

anecdotal records. All, however, contain the following parts,
 Identifying information – pupil’s name, grade, school, and
class
 Date of the observation
 The setting
 The incident
 The signature of the observer. Some contain a section for the
interpretation and recommendation for action.

 The behavioral incident or action should be recorded as soon as possible

after it has happened. Any lapse of time places heavy reliance on the
teacher’s memory, which may become blurred if too much time elapses.
 Keep the anecdote specific, brief and limited to a single incident. Just as
too little information does not help much in having a better understanding
of a pupil’s behaviour, too much information can cloud the real issue.
  Keep the recording process simple
 Keep the anecdote objective. Don’t focus on irrelevant details.
 Although anecdotal records could be compiled on slips of paper, cards or
any material readily handy, we do not recommend using slips of paper,
since they can be easily lost or misplaced. A large sheet of paper is
preferred because it permits the teacher to write her interpretation on the
same sheet as the description of the setting and incident.
 There should be some standard form for filing anecdotal records
 Anecdotal records should not be restricted to recording negative
behaviour patterns. In fact, the anecdotal record should record significant
behaviours regardless of their direction.Only in this way, can the teacher
obtain a valid composite picture of the student.
 The validity of the anecdotal record will be increased with a variety of
common information gathered from different sources. Anecdotal records
should be kept by all teachers and not be restricted to only the class
teacher.

WHERE TO KEEP THE ANECDOTES:

Anecdotal records are highly confidential and must be kept in a safe place,
preferably under lock and key.

GOVT DIST HEAD QRS HOSPITAL

PENNAGARAM (CODE -00034).
DHARMAPURI(DT) Tamil Nadu

APPRAISAL FOLDER
 A. Personal details
S.N Particulars
o
1. Name

2. Age / Sex

3. Employee ID number

4. Residential address

5. Date of medical qualification and

registration in Tamil Nadu Medical Council
(please give date of specialist registration,
and specialties in which registered)
6. Date of first appointment in Tamil Nadu
Medical services
7. Date of posting to the current Health Care
Organization and rank currently held
8. Name of the department and post
currently held (for example: surgeon,
paediatrician, obstetrician, physician etc.)
9. Has your registration been called into
question since your last appraisal? (If this
is the first appraisal, is your registration
currently in question?)
10. List all the posts in which you have been employed in the TNMS and elsewhere in the
past five years
11. Name of the post held Name of the HCO Period

B. Details of Appraise activities record, Appraisers comments and action agreed

S.N Criteria / Activities HS RMO Senior Appraise
o CCS record
1. Attendance and punctuality

2. Discipline / Courteousness
 3. Professional knowledge - Outpatient work, ward
work, surgical activities, emergency care, camp
duties, CMEs, in-service trainings etc.
4. Working relationships with colleagues

5. Ability to train employees / faculty

6. Working relationship with patients

7. Computer knowledge

8. Leadership - Ability to coordinate and facilitate a

collaborative approach to completion of tasks
9. Continuing Professional Development (CPD) /
CME courses attended and points awarded for
each attendance
10. Records of any noteworthy achievements and
any recorded feedback if available
11. Health concerns raised or problems encountered
during the year and documented in any records
12. Any disciplinary proceedings initiated and
completed within the last twelve months?
10 – Excellent8 – Very good 6 – Good 4 – Satisfactory 2 – Improvement required

Appraiser’s comments Action agreed Trainings suggested

We agree that the above is an accurate summary of the appraisal discussion and agreed action,
and of the agreed personal development plan.

Signature of the Appraise with date Signature of Chief Medical Officer

Date: CMO.

GOVT DIST HEAD QRS HOSPITAL, PENNAGARAM (CODE -00034).

COMPETENCY ASSESSMENT AND CLINICAL PRIVILEGING
Name of the Staff Nurse: Employee No.:
Department: Date of Joining:
S.N Competenc Clinical privilege Denie
o SKILLS y d
Yes No Done Under
independentl supervisio
y n
1. Intravenous fluid administration:
a) Peripheral access: Venflon and Butterfly
b) Peripheral lines: Administration/maintenance,
tubing changes, site care
2. Blood/Blood products administration:
Consent.
Administration and monitoring
Discontinuation/ transfusion reactions
3. Medication administration:
a) Administer IV, IM, SC, ID, Oral and Topical
medications
b) Monitor IV infusions
4. Oxygen delivery:
a) Set-up/maintenance
b) Nasal cannula
c) Vent mask
d) Partial and non-rebreather masks
5. Adjunctive Airway management:
a) Use of AMBU bag and care after use
b) Attachment of laryngoscopes blades and care of
laryngoscopes after use
c) Insertion of oral airway
d) Insertion of ET tube
e) Giving nebulisation
f) Suctioning: Oral, nasal and tracheal
6. Tubes/Drains:
a) NG tube insertion, maintenance and removal
b) Urinary catheter placement, maintenance and
removal
7. Infection control practices:
a) Surgical scrub
b) Gowning and gloving technique
c) Standard precautions - use of PPE
d) Disinfection and Sterilization of various items
e) BMW management
 f) Needle Stick Injury policy
g) Hazard material spills management
h) Handling of linen
8. a) Suture needs/availability
b) Instrument trays
c) N2O,Oxygen supply, vacuum
d) Prosthetic device/Implants
9. Administration of medications:
a) Pre-operative prophylactic antibiotic
b) Intra-operative antibiotics
c) Emergency drugs
d) HRM administration and monitoring
e) Drug reactionawareness
10. a) Wound culture
11. Handling blood and tissue specimens:
a) Labelling specimens and transport for biopsy
b) Blood samples for various tests
12. Emergency codes awareness:
Code blue, code red, code pink, code yellow, code
black, code white, code purple, code orange
13. Fire safety:
Knowledge about the use of fire extinguishers
14. Procedural knowledge:
a) Otorhinolaryngology:
Ear lobe repair, Tonsillectomy with Adenoidectomy,
FESS, Nasal Polypectomy, Mastiodectomy
b) Obstetrics & Gynaecology:
D & C, Caesarean section, Colposcopy,
Marsupialisation – Bartholin cyst, Abdominal
Hysterectomy, Vaginal hysterectomy, Laparoscopy
sterilization, Salphingo- oophorectomy
c) Orthopaedics:
Closed manual reduction of fractures and joint
dislocations
Amputation of limbs, Patellectomy, Achilles tendon
repair
External Fixator application – Extremities, ORIF with
compression plates, Intra and peri-articular steroid
injection.
d) General Surgery:
SSG, Vasectomy, Fissurectomy, Haemorrhoidectomy,
 Sphinterotomy, Hydrocele saceversion, Hernioplasty,
Hernioraphy, Laparotomy, Thyroidectomy,
Parotidectomy, Dignosticlaproscopy,Laparoscopic
Appendicectomy, LaparoscopicCholecystectomy, Fine
Needle Aspiration Cytology (FNAC), Excision of lumps,
Mastectomy, Appendicectomy, GI perforation
closure, Biopsy procedures – breast, lymph node
15. Documentation:
a) Verification of consent for surgery, anaesthesia,
current investigation results, Pre-operative
anaesthesia assessment, Pre-induction
anaesthesia assessment, Pre-operative check list
and pre-operative orders
b) Site marking, Surgery identity card
c) Safe surgery check list - time in, time out, sign out
d) Recovery signs and Aldrete score chart
e) Pain management document
f) Allergy history and recording vital signs
g) Gives thorough report to recovery nurse
16. Cognitive or social skills:
a) Communication – Non verbal and Verbal
b) Teamwork
c) Leadership
d) Situation awareness and decision-making
e) Aesthetic knowledge

I hereby certify that I am sound by physical and mental health

Signature of Applicant
with name and date

This Annual Competency Assessment Tool certifies that

____________________________________________________
has been revalidated for the above skills for the review period
_______________________________________________
Validated and recommended by:
 Signature of Nursing Superintendent
with name and date Approved by:

Date: CMO.
GHQH PENNAGARAM
Place: PENNAGARAM

ADVANTAGES:

The advantages of anecdotal records are as follows,

 Supplements and validates other structured instruments.

 Provision of insight into total behavioural incidents.
 Use of formative feedback.
 Economical and easy to develop. It helps in clinical service practices.
Direct the teacher’s attention to a single pupil.

DISADVANTAGES:
The disadvantages of anecdotal records are as follows,

 If carelessly recorded, the purpose will not be fulfilled.

 Subjectivity.
 Lack of standardization.
 Time consuming.
 Limited application.

CONCLUSION

Reports are of prime importance both to good ward administration and to a

well-functioning hospital. A report to be of greatest use and to save time and to
prevent duplication of work

BIBLIOGRAPHY:

1. Basavanthappa, B. T., "Nursing Administration", 2nd Edition, Jaypee

Brothers Publishers, New Delhi, 2008.P-250-252.
2. N.W. Yalayyaswamy, "Ward Management and supervision and
professional Adjustments and Trends for Nurses in India, "Gajana book
publishers. Bangalore. 2003.pp 240-246.
 3. Barbara Kozier, Glenora Erb.Janice.s. Hayes, Kathleen Koenig Blais,
Professional Nursing practice concepts and perspectives"5" edition.
Dorling Kindersley publishers, New Delhi, 2006.pp 42 to 46
4. B. Sankara Narayan, B. Sindhu 3 edition Calicut, Kerala 2009. 5. KP
Neeraja Textbook of Nursing Education. 1 Editon New Dellu: Jaypee
Brothers Medical Publishers, 2003.

NET REFERENCE

www.wikipedia.com

www.pubmed.com