Records and Reports
Records and Reports
Records and Reports
Legal evidence
It avoids duplication of treatment measures
It avoids duplication of diagnostic and procedural measures
It will assist in continuity of patient care
It helps in health insurance of the patient
Communication
Education
Assessment
Documentation of continuity and justification of case
Research
Auditing
Legal documentation
Individual case study
Records and reports play an important part in nursing education programme. Apart from
being necessary for the day to day administration of school of nursing; they provide
continuity from the time the school is established, thus facilitating evaluation of the
programme.
Types of Records
They types of records usually kept in a school office may be divided into 3 categories.
1. Those concerning students:
Application forms and other reports called for at the time of recruitment, selection
and appointment, such as references, medical reports, school records and result of
any test carried out at the time of selection.
A record of each students clinical performance.
A progress report showing grades and other pertinent information.
A final record/permanent record giving a summary of instruction, clinical experience,
grades and relevant material.
A health record.
Admission record.
Anecdotal record.
1. Admission register
2. Students attendance register
3. Clinical experience records
4. Students health records
5. Staff attendance records
6. Acquittance register
7. Internal assessment register
8. External marks register
9. Report of various committee
Application forms.
Copy of letter of appointment (or posting order) and any subsequent letter showing
changes in status.
Job description what candidate is expected to do in each category.
Record of staff member's educational qualification, previous experience, any short
term educational courses attended, membership in professional society such as
contribution of articles in journals, holding office in associates or organization,
participation in seminars, conference etc.
Periodic evaluation or progress report.
Leave record.
Health record.
Anecdotal record.
REPORTS
The number and nature of reports will be depending on what is required by the controlling
body and nursing council.
The type of information which is commonly required in an annual report is as follows:
Role of Administrator
The nurse administrator should see that every body is following common guidelines for
recording information: