Record and Report

RECORD AND REPORT
COMMUNITY HEALTH NURSING
Record and Report

(Recording & Reporting)
Ram Sharan Mehta, Ph.D.
RECORDS
A record is a permanent written communication that documents information relevant to a client's
healthcare management, e.g. a client chart is a continuing account of client's healthcare status
and need.
-Potter and Perry
PURPOSES OF RECORDS
1. Supply data that are essential for programme planning and evaluation.
2. To provide the practitioner with data required for the application of professional services
for the improvement of family's health.
3. Records are tools of communication between health workers, the family and other
development personnel.
4. Effective health records shows the health problem in the family and other factors that
affect health.
5. A record indicates plans for future.
6. It provides baseline data to estimate the long-term changes related to services.
ADMINISTRATIVE PURPOSE OF CLINICAL RECORDS

1. Legal Documents: Poisoning, Assault, Rape, LAMA, Burn, etc.
2. Research or Statistics: Rates
3. Audit and Nursing Audit
4. Quality of Care
5. Continuity of Care
6. Informative Purposes: MEN census
7. Teaching Purpose of Students
8. Diagnostic Purposes: Test Reports
IMPORTANCE OF RECORDS IN HOSPITAL

1. For the individual and family:
√ Serve the history of the client
√ Assist in the continuity of care
√ Evidence to support if legal issues arise
√ Assess health needs, research and teaching.
2. For the doctor:

√ Serve the guide fir diagnosis, treatment, follow-up and evaluation
√ Indicate progress and continuity of care
√ Self Evaluation of medical practice
√ Protect doctor in legal issues
√ Used for teaching and research
3. For the nurses:

√ Document nursing service rendered
√ Shows progress
RECORD AND REPORT
√ Planning amd evaluation of service for future improvement

√ Guide for professional growth
√ Judge the quality an quantity work done
√ Communication tool between nurse and other staff involved in the care.
√ Indicate plan foe future
4. For authorities:
√ Statistical Information
√ Administrative Control
√ Future Reference
√ Evaluation of Care in terms of quality, quantity and adequacy
√ Help supervisor to evaluate service
√ Guide Staff Students
√ Legal Evidence of Service Render by Each Employee
√ Provide justification of expenditure of funds
PURPOSES OF RECORDS: SUMMARY

1. Communication
2. Financial Billing
3. Education
4. Assessment
5. Research
6. Auditing and Monitoring
7. Legal Aspect
RECORDS IN THE NURSING OFFICE & UNIT

 Administrative Records: Organogram, job description, procedure manual
 Personal Records: Personal Files, Records
 Patient Related Records: Patients Record Send to Medical Director, Leave Record, duty
roster, meeting minutes, budget, etc.
 Miscellaneous: Circular, round book, formats, etc.
PRINCIPLES OF RECORD WRITING

1. Nurses should develop their own method of expression and form in record writing.
2. Records should be written clearly and appropriately
3. Records should contain facts based on observation, conversation and action.
4. Select relevant facts and the recording should be neat, complete and uniform
5. Records should be written immediately after an interview
6. Records are confidential document.
FILLING OF RECORDS
Different systems may be adopted depending on the purposes of the records and on the merits
of the system.
The records could be arranged:
√ Alphabetically
√ Numerically
√ Geographically and
√ With index cards
RECORD AND REPORT
REGISTERS
• It provides indication or the total volume of service and type of cases seen. Clerical
assistance may be needed for this. Registers can be varied type such as:
 Immunization register
 Clinic Attendance Register
 Family Planning Register
 Birth Register
 Death Register
GUIDELINES FOR QUALITY DOCUMENTATION AND REPORTING

a. Factual basis
b. Accuracy
c. Completeness
d. Organization
e. Confidentiality
NURSES RESPONSIBILITY FOR RECORD KEEPING AND REPORTING

• Keep under safe custody of nurses
• No individual sheet should be separated
• Not accessible to patients and visitors
• Strangers are not permitted to read records
• Records are not handed over the legal advisors without written permission of the
administration
• Handed carefully, not destroyed
• Identified with bio-data of the patients such as the name, age, admission number,
diagnosis, etc. (Legal issues)
• Never sent outside of the hospital without the written administrative permission.
PATIENT VERIFICATION
• Two identifiers: Patient's name and birth date
• Compare of ID Band, consents, diagnostic images, and all other patient
documentation related to the procedure.
SYSTEM OF MEDICAL RECORD

• In the modern age, medical record has the utility and the usefulness and is a very
broad based indicator of patients care.
• The policy is to keep indoor patient records for 10 years
• The OPD registers for 5 years
• The record which is register for legal purposes in maintained for 10 years for till
final decision at the court of the law.
FUNCTIONS OF MEDICAL RECORD DEPARTMENT

1. Daily receipt of case sheets pertaining to discharge and expired patients from various
wards, there checking and assembly.
2. Daily compilation of hospital census report
3. Maintains and retrieval of records for patient care and research study.
RECORD AND REPORT
4. Completion and processing of hospital statistics and preparation on different periodical

reports on morbidity and mortality.
5. Online registration of vital event of birth and death
6. Issuing birth and death certificated up to one year.
7. Dealing with medico-legal records and attending the courts on summary
8. Arrangement and supervision of inquiry and admission office
REPORTS
• Reports can
be compiled daily, weekly, monthly, quarterly and annually
•Report summarizes the services of the nurse and/or the agency
•Reports may be in the form of an analysis of some aspect of service
•These are based on records and registers and so it is relevant for the nurses to
maintain the records regarding their daily case load, service load and activities
• Thus the data can be obtained continuously and for a long period.
NURSING REPORTS
• Reports are information about a patient either written or oral
- Sr. Nancy
• A report is a summary of activities or observations seen, performed or heard
- Potter and Perry
PURPOSES OF THE WRITING REPORTS

• To show the kind and quantity of service rendered over a specific period.
• To show the progress of in reaching goals
• As an aid in studying health conditions
• As an aid in planning
• To interpret the services to the public and to other interested agencies.
TYPE OF REPORTS
1. Change of Shift Report
2. Telephone Reports
3. Telephone Orders
4. Transfer Reports
5. Incident Reports
6. Legal Reports
CRITERIA OF A GOOD REPORT

• Can be made promptly
• Clear, concise, and complete
• All pertinent, identifying data included
• Mention all people concerned, situation and signature of person making report
• Early understood
• Important points are emphasized
KEY MESSAGES
• Written policies and procedures are the backbone of the quality system
• Complete quality assurance records make quality management possible
• Keeping records facilitates meeting program reporting requirements
RECORD AND REPORT
Records and reports revels the essential aspects of service in such logicak order so that the new
staff may be able to maintain continuity of service to individuals, families and communities.
TYPES OF RECORDS
1. Periodical
A. Permanent Records (Cumulative)
B. Temporary Records (casual/daily records)
2. Unit Based
A. Individual (individual health cards)
B. Related to family (family folders)
C. Related to community (community folders)
a. Records to be kept under health center
1. Family folders
b. Records to be kept with patient
D. National (national health programs records)
3. Subject Based
A. Economical (financial structure of family, village)
B. Social (records of social structure)
C. Political
D. Medical and nursing (treatment and medicine records)
4. Collection Placed Based
A. Collected at institution (records of hospital/ health centers)
B. Records to be kept within individual (immunization cards, disease cards)
Important Health Records

1. Daily Diary – daily activities of community health nurse
2. Village record – consist of:
a. Name of village
b. Distance from health center
c. Total number of families
d. Total population
e. Religious beliefs
f. Number of woman under different age groups

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What are the purposes of records?

What are the purposes of records?

What are the principles of record writing?

What are the principles of record writing?

RECORD AND REPORT

COMMUNITY HEALTH NURSING

Record and Report

ADMINISTRATIVE PURPOSE OF CLINICAL RECORDS

IMPORTANCE OF RECORDS IN HOSPITAL

2. For the doctor:

3. For the nurses:

√ Planning amd evaluation of service for future improvement

PURPOSES OF RECORDS: SUMMARY

RECORDS IN THE NURSING OFFICE & UNIT

PRINCIPLES OF RECORD WRITING

GUIDELINES FOR QUALITY DOCUMENTATION AND REPORTING

NURSES RESPONSIBILITY FOR RECORD KEEPING AND REPORTING

SYSTEM OF MEDICAL RECORD

FUNCTIONS OF MEDICAL RECORD DEPARTMENT

4. Completion and processing of hospital statistics and preparation on different periodical

PURPOSES OF THE WRITING REPORTS

CRITERIA OF A GOOD REPORT

Important Health Records

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