MKSSS SITABAI NARGUNDKAR

COLLEGE OF NURSING FOR WOMEN

SUBJECT: NURSING MANAGEMENT

ASSIGNMENT ON:
DAY AND NIGHT REPORT

Submitted To Submitted By
Ms. Vandana S. Thangavel Ms. Rupali S Kharabe
HOD of MHN Dept, MSc Final Year (N) MHN
MKSSS SNCON, Nagpur MKSSS SNCON, Nagpur

Submitted On
17/03/2025

DAY AND NIGHT REPORT

 INTRODUCTION...
Communication is corner stone in the nursing professional and essential part of the
nursing care. Nurses communicate information about clien’s/ patien’s so that all health
care team members can make appropriate decision making about clien’s care.

DEFINITION

1. It is oral, written or computer based communication intended to convey information.

2. REPORTS are oral or written exchange of information shared between
care givers ( Health care team) in a number of ways.

PURPOSES OF RECORDING AND REPORTING :

DECISION MAKING.
COMMUNICATION
REIMBURSEMENT.
LEGAL ACCOUNTABILITY.
EDUCATION.
ASSESSMENT.
PLANNING.RESEARCH.
AUDIT.
HISTORICAL DOCUMENT.
QUALITY ASSURANCE.
VITAL STATISTICS.
HEALTH SERVICE PLANNING.
DIAGNOSTIC AND THE THERAPEUTIC ORDERS

TYPES OF REPORTING IN NURSING

  Oral reports
 Written reports

DAY AND NIGHT REPORT

TRANS- TRANS-
UNIT REMAININ NEW FER FER OUT DAMA DEATH ABSCOND DISCHARG TOTAL
G PATIENT ADMISSIO IN E
N

I 10 01 01 01 01 12

II 08 05 03 10

III 09 00 09

IV 06 06

TOTAL PATIENT - 37

DAY REPORT
 Day report is to provide means of transferring important information about the patients to
the head nurse, the ward nurses, night nurses, nursing officer and the day and night supervisors.

We M. Sc. Nursing 2nd year student were posted in labor ward for administration duty in
the morning shift from 8:00 AM to 4:00 PM.

We supervise the students & all staffs posted in this ward. We helped the in charge of this
ward in various works like counting inventory, making duty lists, indenting the medicine as per
requirements, to assist in normal vaginal delivery & instrumental vaginal delivery. The indenting
procedure occurs twice in a month.

The P.B.Sc nursing students were also posted for caring of the clients.

Two staffs were there along with two attendant for making calls & cleanliness even they play
major role during day time like sending the clients for investigation.

We assigned the students for daily caring of the clients according to their strengths. After
the assignments these students put the signature in the student assignment note book under
supervision. We have given incidental teaching to B. Sc. Nursing students for giving the health
education regarding Labor Process, Partograph, Breast Feeding Technique, KMC, D& C.

Supervision of students in following procedures:

• Labor Table Preparation

• Intravenous infusion

• Daily weight recording

• Doing perineal care.

• Maintaining Partograph

• Administration of medication with the help of the staffs posted in the ward

• Maintaining intake output chart.

• Attending doctors and sisters round.

• Taking vital signs

• Providing health education to the clients & family members before discharge.
 We the all nursing personnel make the rounds with the consultant along with the Doctors who
were posted in the pediatric ward. We discussed about the patient’s condition with them.

We supervise the work of staff are as follows

• Administration of medication I/M, oral & I/V

• Making indent

• Record maintenance including nurses notes

• Maintaining the ward registers like admission, discharge, diet, student assignment,
medicine register, investigation register, dhobi register etc.
• They prepare the special report if death of the client is occurs.

I helped the In charge of the ward in the following way: Routine

work

1. Admission & discharge of patients.

2. Planning nursing care and makes patient assignments as per their nursing needs.

3. Ensures safety, comfort and good personal hygiene of patient.

4. Assists in planning and administration of therapeutic diet of the patient.

5. Ensures the helpless patients are regularly fed as per direction.

6. Ensures that proper observation records of the patient are made and necessary
information imparted to the concerned authorities.
7. Takes nursing rounds with staff and students.

8. Makes rounds with doctors, assisting in care and treatment of the patients.

9. Implements doctors instructions concerning patient treatment.

10. Assisting in patient and his/her relatives to adjust in hospital and its daily routine.

11. Coordinates patient care with other departments.

12. I helped her in making staffs duty roster.

Supervision and administration

1. Ensures safe and clean environment for the ward/ unit/special department.
2. Makes duty and work assignments.

3. Indenting and procurement of ward supplies and equipments and keep records.

4. Does regular inventory checking of the ward/ unit.

5. Makes list for condemnation of articles and submit’s it to all the concerned.

6. Assists in making ward requirement.

7. Establishes and reinforces the standards prescribed in the procedures and manuals of
the hospital and policies that are in force..
8. Maintains good public relation between her staff unit.

9. Ensures that ward statistics are regularly submitted or not.

10. Maintains discipline among the personnel working in the particular ward/unit, eg.
Staff nurses, student nurses and domestic workers.
11. Deals appropriately with any adverse situation that occurs in ward or unit and report
to the concerned authorities.
12. Reports about any medico-legal cases in the ward/ unit

13. Writes and submits confidential reports of the staff to the concerned authority.

14. Ensures that students get desired learning experience in the Ward/unit.

FORMAT OF DAY REPORT

 S.N. Name of the Diagnosis Instructions Remark
Patient
1. Mrs. Sangeeta ❖ LSCS with ❖ Liquid diet

fetal distress. ❖ Maintain intake and output

chart.

❖ Continue antibiotics.

❖ SOS analgesics

❖ Maintain 4 hourly vital signs.

❖ Dressing change

Sign of Duty Nurse : Sign of Nursing

Superintendent
Date: Date:
 NIGHT REPORT
Night reports is to provide means of transferring important information about the patients
to the head nurse, the ward nurses, night nurses, nursing officer and the day and night
supervisors.

I was posted in OBG ward for night duty. For night duty two staff nurses were there in ward.

• We assisted sister for giving medication, monitoring vital signs, new

admission procedure, night recording & reporting.
• Preparing patient for next day diagnostic procedure & surgery.
• Records of patients transfer in & transfer out is maintained.
• Night report is prepared & submitted to matron office.
• At 6:00 am assisted for giving medication.
• Hand over was given to the morning duty staff at 7:30am.
• We had a night round with sister from 10:30pm to 1:30am; we started round with
pediatric ward, eye ward, male & female medicine, ICU, HDU, pediatric ward, ENT
ward, male & female surgery, casualty & we finished with orthopedic ward.
• During night round in each ward night supervisor asked about new admission after
evening, any emergency occurred, on duty attendant, tally of general order book with
doctor’s order, cleanliness & tidiness of ward is also seen.
• We have been assigned to prepare bed list of the hospital.
• Collection of bed list from different department & then final bed list was prepared
we completed it till 4:30 am.
• In matron office we have seen various registers like night report register for each floor &
separate for casualty.
• Final night report was prepared
 FORMAT OF NIGHT REPORT

S.N. Name of the Patient Diagnosis Instructions Remark

Signature of the Duty Nurse Signature of the Nursing Superintendent

Date: Date:
 SAMPLE OF DAY AND NIGHT REPORT ACCORDING TO NUMBER
OF BEDS

Bed Name & Diagnosis Morning Evening Night

no. age shift shift shift

Signature of In charge: