records and reportsin phc.pptx

Nursing Records and
r e p o r t s

DEFINITION
1. Records the memory of the internal and external
transactions of an organization. Records contain a written
evidence of the activities of an organization in the form of
letters, circulars, reports, contracts, invoices, vouchers,
minutes of meeting, books of account etc.
Accordingto S.L.Geol, 2001
2. It is a written communication that permanently
documents information relevant toa client’s health care
management. It is a continuing account of the client’s
health careneeds
AccordingSr.Mary lucita]

PRINCIPLES OF MAINTAINING
RECORDS
1. Specific purpose which should be clearly understood
2. Items on forms and in registersshould be conveniently grouped soasto make
their completion aseasyaspossible.
3. Thewording shouldbe easily understood,andwhere doubt is likely to arise,
instructions to facilitate interpretation should be included.
4. Recordsshould permit some freedom ofexpression.
5. Recordswhich are required by the teaching staff should be easily accessible
to them.
6. Personresponsible for maintaining records should be aware of their
particular responsibility and every effort should be made to keeprecords up
to dateand accurate.

PRINCIPLES OF MAINTAINING
RECORDS
7. Provision for periodic review of all records to ensure that they keep
pace with the changing needsof theprogramme.
8. Adequate supply of stationery to permit records to be maintained on
the proper forms and in the proper registers at all times.
9. Sufficient number of filing cabinets and appropriate equipments to
operate afiling system which is simple and safe and requires the
minimum possible time.
10. Adequate, safe, fireproof storage arrangements

CHARACTERISTICS OF RECORDS
ACCURACY
CONSCIOUSNESS
THOROUGHNESS
UPTO DA
TE
ORGANIZATION
CONFIDENTIALITY
OBJECTIVITY

PURPOSE OF KEEPING
RECORDS
1. Communication
2. Aidsto diagnosis
3. Education
4. Documentation ofcontinuity
5. Research
6. Legaldocumentation
7. Individual casestudy

USES OF RECORDS
1. Showthe health conditions asit is and asthe patient and family
acceptsit.
2. goals towardswhich meansare to be directed.
3. prevents duplication of services and helps follow up services
effectively.
4. Helps the nurses to evaluate the careand the teaching
5. Organization of work
6. Servesasaguide for diagnosis treatment and evaluation of
services
7. indicate progress
8. Used in research
9. Thehealth assets and needs of the villagearea

T Y P E S OF RECORDS
1) P
A
TIENTSCLINICAL RECORD
2) INDIVIDUALST
AFFRECORDS
3) WARDRECORDS
4) ADMINISTRATIVERECORDSWITH
EDUCATIONALVALUE.

1) PATIENTSCLINICALRECORDS
 It is the knowledge of eventsin the patient illness, progress in his
or her recovery and the type of care given by the hospital
personnel-
A. Scientific andlegal
B. Evidence to the patient the his /her caseis intelligently managed.
C. Avoids duplication of work.
D. Information for medical and legal nursingresearch.
E. Aids in the promotion of health and care.
F. Legal protection to the hospital doctor and the nurse

PATIENTSCLINICALRECORDS
NURSINGADMINISTRATOR’SRESPONSIBILITY
Protection from loss
Safeguarding itscontents
Completeness
Responsibility fornurses notes.
Legalvalue of nursesnotes.
Admissionrecord.
Scientificvalue of the nursesnotes
Recordof order carriedout.

2. INDIVIDUALSTAFFRECORDS
• Aseparate set of record is needed for staff,
giving details of their sickness and absences,
their carrier and developmentactivities and a
personnelnote

3. WARDRECORDS
Reducingor increase inbeds.
Changein medical staff and non nursing
personnel for theward.
Theintroduction and pattern of support.

4. ADMINISTRATIVERECORDSWITH
EDUCATIONALVALUE
Treatments.
Admissions.
Equipments lossesandreplacements
 Personnelperformance.
 Other administrativerecords

T Y P E S OF RECORDS IN THE
DEPARTMENT OF PUBLIC
HEALTH
1. CUMULATIVEORCONTINUINGRECORDS
2. FAMIL
YRECORDS
3. REGISTERS
4. REPORTS

1. CUMULATIVEORCONTINUING
RECORDS
• This is found to be time saving, economical and also it is
helpful to review the total history of an individual and
evaluate the progress of along period.
• Acumulative record is asystematicaccount of information
about a student. It is an evaluation tool which presents a
comprehensive record of the achievement or otherwise of
each student in different aspect-physical academic, moral,
social and health.

2. FAMILYRECORDS
 All records, which relate to members of family, should be
placed in asingle family folder. Gives the picture of the
total services and helps to give effective, economic service
to the family asawhole.
 Separate record forms may be needed for different types
of service suchasTB,maternity etc. all suchindividual
records which relate to members of one family should be
placed in asingle family folder.

GUIDELINES FOR DOCUMENTATION
AND RECORD KEEPING
The Nursing and Midwifery Council (NMC 2002) has said that
patient and client recordsshould:
1. be based on fact, correct and consistent
2. be written assoon aspossible after an event has happened
3. be written clearly and in such away that the text cannot be
erased
4. be written in such away that any alterations or additions are
dated, timed and signed, sothat the original entry is still clear
5. be accurately dated, timed and signed, with the signature
printed alongside the first entry
6. not include abbreviations, jargon meaningless phrases,
irrelevant speculation and offensive subjective statements
7. be readable on any photocopies

IMPORTENCE OF RECORDS IN
HOSPITAL OR HEALTH CENTERS.
1. INDIVIDUALANDFAMIL
Y
2. FORTHEDOCTOR
3. FORTHENURSE
4. FORAUTHORITIES

VALUE AND USES OF RECORDS IN
HOSPITAL AND HEALTH CENTRE
1.FOR THE INDIVIDUAL AND FAMIL
Y
I. Recordsserveto document the history of the
client.
II. Recordsassist in the continuity ofcare.
III. Recordsserve asevidence to support or to
manageor face the legal questions thatarise.
IV. Recordsserve to recognize the health needsand
can be used asaresearch and teaching tool.

2. FORTHEDOCTOR
I. Servesasguide for diagnosis, treatment,follow
up and evaluationof services.
II. Indicateprogress and continuity of care.
III. Help self evaluation of medical practice.
IV. Protect the doctor in caseof legal issues.
Recordsmay be used for teaching and
research.

3. FORTHENURSE
I. Provide with documentation of services
rendered, i.e. shows health condition ofthe
client.
II. Provide data essential for planning andevaluation
of services for furtherimprovement.
III. Serveasaguide for professional growth.
IV. Enable to judge the quality and quantity of work
done.
V. Serveascommunication tool between staffand
other members involved incare.
VI. Indicate plans for the future. ForAuthorities
VII.Provide the management with stati

4. FORAUTHORITIES
I. Provide the management with statistical
information necessaryfor decision in regard to
utilization of resources, planning for
administrativecontrol and future references.
II. Help the supervisor evaluate the services
rendered, teaching doneand aperson’s action
and reactions

RECORD MAINTENANCE IN
COMMUNITY SETTING
1.FORMS,CASECARDSANDREGISTERS.
i. Family record
ii. Eligible couple and child register
iii. Sterilization and IUD register
iv. MCHCard/ register
v. Child Card/ register
vi. Birth and deathregister
vii. Subcenters/PHC/clinic register
viii. Stock& Issueregister
ix. Reports of blood test of Malariaand Filaria
x. Malaria parasite positive caseregisterand
others

2.DIARIES
i. Diary of (M andF)
ii. Diary of HA(M andF)
3.RETURN-
i. Monthly report of HW ( M andF)
ii. Complication report of HW (M andF)
PHCMonthly report In addition, each organization should
maintain:
i. Cumulative records
ii. Family records

RECORD MAINTENANCE IN
HOSPITAL
i. Thepatient’s clinicalrecord
ii. Recordsof nurses’observations –Nurses’
Notes
iii. Recordsof orders carried out
iv. Recordsof treatment
v. Recordsof admission anddischarge
vi. Recordsof equipment lossand replacement(
inventory)
vii. Recordsof personnelperformance.

DEFINITION
1. Areport containing information against in anarrative graphic or
tabular form, prepared on periodic, receiving, regular or asa
required basis. Reports mayrefer to specific periods, events,
occurrence, or subject and maybe communicated or presented
in oral or written form
Accordingto BASV
ANTHAPP
ABT.2009
2. Reports are oral or written exchanges of information shared
between care givers of workers in anumber of ways.Areport
summarizes the service of the personnel and of theagency
According to JEANB.2002

P UR P O S ES
1. Reportis anessentialtool to communication
2. T
oshow the kind and amountof services
rendered over aspecificperiod.
3. T
oillustrate progress in teachinggoals.
4. Asan aid in studying healthcondition.
5. Asan aid in planning.
6. T
ointerpret the services to the public and to
the other interestedagencies.

CRITERIA FOR A GOOD
RE P O RT
1. Madepromptly.
2. Clear,concise, andcomplete.
3. If it is written all pertinent, identifying data are
included-the date and time, the people
concerned, the situation, the signature of the
person making thereport.
4. It is clearly stated and well organized
5. Important pointsare emphasized.
6. In caseof oral reports they are clearly
expressed and presented in aninteresting
manner.

R E P O R T S IN NURSING
EDUCATION
1. Factualdata related to the students,staff,
clinical facilities, physical facilities,
administrationand the curriculum
2. Development made in the schoolprogramme
since the lastreport.
3. Proposaland plansfor future development.
4. Problems encountered
5. Recommendations

T Y P E S OF R E P O R T S
1. 24 hoursreports
2. Censusreport
3. Anecdotalreport
4. Birth and deathreport
5. Incidental report

CLASIFICATION OF R E P O R T S
B A S E D ON T Y P E S
1. ORALREPORTS
2. WRITTEN REPORTS
1. ORALREPORTS: Oral reports are given when the
information is for immediate useand not for permanency.
 E.g.it is made by the nurse who is assigned to patient care,to
another nurse who is planning to relieve her.
2. WRITTENREPORTS: Reports are to be written when the
information to be used by several personnel, which is more or
lessof permanent value,
 E.g.day and night reports, census,interdepartmental reports,
needed according to situation, events and conditions.

R E P O R T S USED IN HOSPITAL
SETTING
1. CHANGE– OF– SHIFTREPORTS
2. TRANSFERREPORTS
3. INCIDENTREPORTS
4. LEGALREPORTS

ADVANTAGES AND
DISADVANTAGES OF R E P O R T S
 Monitoring operations
 Controlling
 Guide decision
 Employeemotivation
 Performance evaluation
 It is timeconsuming.
 Expensive
 Reports can be biased
 Sometimes implementations
of the recommendations of a
report becomeunrealistic.
 Technical reports are not
easily understandable

NURSES RESPONSIBILITY FOR
RECORD KEEPING AND
REPORTING
• Records and reports must be functional
accurate, complete, current organized and
confidential
1. F
ACTS
2. ACCURACY
3. COMPLETENESS
4. CURRENTNESS
5. ORGANIZATION
6. CONFIDENTIALITY

1 .FACT
• Information about clients and their care must be
functional. Arecord should contain descriptive,
objective information about what anursesees,hears,
feels and smells.
2. ACCURACY
• Aclient recordmust be reliable. Information must be
accurate sothat health team members have
confidence in it.
3.COMPLETENESS
• Theinformation within arecorded entry or areport
should be complete, containing concise andthorough
information about aclient care or anyevent or
happening taking place in the jurisdiction ofmanger.

4. CURRENTNESS
• Delaysin recording or reporting canresult in serious
omissions and untimely delays for medical care oraction
legally, alate entry in achart may be interpreted on
negligence.
5. ORGANIZATION
• Thenurse or nurse manager communicatesinformation
in alogical format or order. Health team members
understand information better when it is given in the
order in which itis occurred.
6. ONFIDENTIALITY
• Nursesare legally and ethically obligated to keen
information about client’s illnesses andtreatments
confidential

records and reportsin phc.pptx

records and reportsin phc.pptx

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