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MODULE 6
Module Title: Records in Family Health Nursing Practice

Overview:
An effective health record shows the extent of the health problems’ needs and other factors that
affect individuals their ability to provide care and what the family believes. What has been done and what to
be done now also can be shown in the records. It also indicates the plans for future visits to help the family
member to meet the needs.

RECORDS are necessary for the continuation of delivery of family health care services and it’s
evaluation while evaluation of family health services is necessary to identify the new and continuing family
health needs.

FAMILY RECORDS include information based on factual events, observation results or

measurements taken such as height, weight, body circumference or laboratory examinations carried out
like hemoglobin, urine test, stool test and sputum examination depending upon the problem of the family.
These also includes of immunizations, nutrition status, medical prescription and curative procedures carried
out. Demographic data and individual personal history are also included in the family folders.

HEALTH RECORDS refer to forms on which information about an individual and family is noted.
Information varies from socio-economic, psychological, environmental factors etc. Records are a practical
and indispensable aid to the doctor, nurse, and other health care workers in giving best service to
individual, family or community. Recorded facts have value and scientific accuracy and are guidelines for
better administration of family health services. Contributions of health team members are reflected in case
records. Records are also a means of communication between a health worker and the families
REPORTS are oral or written exchanges of information shared between caregivers or workers in
several ways. Also, it’s the summary of the services of person or personnel and of the agency.

Module Objectives:
At the end of this module, the student should be able to:
1. Apply knowledge of physical, social, natural and health sciences, and humanities in the care of the
individual and family in the community setting.
2. Apply guidelines and principles of evidence-based practice in the delivery of care to the individual
and family in the community setting.
3. Adopt the nursing core values in the delivery of care to individual and families.

Module Coverage
A. Topic: Importance and Uses
B. Topic: Types of Records and Reports

TOPIC A
Topic Title: Importance and Uses
Topic Contents:

A. IMPORTANCE AND USES

 Provides documentation of services that have been rendered and supply data that are essential for
program planning.
 To provide the practitioner with data required for application of professional services for
improvement of family's health
 Records are tools of communication.
 Effective health record shows health problem in the family and other factors that affect health-
standardized sheet/form.
 Records indicate a plan for future.
 Provides baseline data to estimate long-term changes related to services.
 Provides opportunity for providing evaluation of the situation.
 Purpose of documenting Family Health History which is an important component of family health
records are the following:
 Provides facts that are necessary for evaluating health situation of the family; it should also
describe the nature and impact on health threat. It should describe the health condition and
interacting forces within the family in their daily living.

PURPOSES OF RECORDS
1. Supply data that are essential for programmes 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 show 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.

PRINCIPLES OF RECORDS WRITING

 Nurses should develop their own method of expression and form in record writing.
 Written clearly, appropriately, and adequately.  Contain facts based on observation, conversation,
and action.
 Select relevant facts and the recording should be neat, complete and uniform  Valuable legal
documents and so it should be handled carefully and accounted for.
 Records should be written immediately after an interview.
 Records are confidential documents.
 Accurately dated, timed, and signed
 Not include abbreviations, jargon, meaningless phrases

VALUES AND USES OF RECORDS IN HOSPITAL OR HEALTH CENTERS

For the Individual and Family
1. Records serve to document the history of the client.
2. Records assist in the continuity of care.
3. Records serve as evidence to support or to manage or face the legal questions that arise.
4. Records serve to recognize the health needs and can be used as a research and teaching tool.
For the Doctor
 1. Serves as guide for diagnosis, treatment, follow up and evaluation of services.
2. Indicate progress and continuity of care.
3. Help self-evaluation of medical practice.
4. Protect the doctor in case of legal issues. Records may be used for teaching and research.

For the Nurse

1. Provide with documentation of services rendered, i.e. shows health condition of the client.
2. Provide data essential for planning and evaluation of services for further improvement.
3. Serve as a guide for professional growth.
4. Enable to judge the quality and quantity of work done.
5. Serve as communication tool between staff and other members involved in care.
6. Indicate plans for the future

For Authorities
1. Provide the management with statistical information necessary for decision in regard to
utilization of resources, planning for administrative control and future references.
2. Help the supervisor evaluate the services rendered, teaching done and a person’s action and
reactions.

TYPES OF RECORDS

1. Cumulative or continuing 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 a long period.
2. Family records
 All records, which relate to members of family, should be placed in a single family folder.
Gives the picture of the total services and helps to give effective, economic service to the
family as a whole.
 Separate record forms may be needed for different types of service such as TB, maternity
etc. all such individual records which relate to members of one family should be placed in a
single family folder.

RECORDS MAINTAINED IN THE COMMUNITY SETTINGS

1. Forms, case cards and Registers.

 Family record
 Eligible couple and child register
 Sterilization and IUD register
 MCH Card/ register  Child Card/ register
 Birth and death register
 Sub centers/PHC/clinic register
 Stock & Issue register
 Reports of blood test of Malaria and Filaria
 Malaria parasite positive case register and others
2. Diaries – Diary of (M and F) Diary of HA (M and F)
3. Return- Monthly report of HW (M and F) Complication report of HW (M and F) PHC Monthly report
in addition, each organization should maintain
 a. Cumulative records
b. Family records

HOW TO IMPROVE RECORD-KEEPING

 Get into the habit of using factual, consistent, accurate, objective and unambiguous patient
information
 Use your senses to record what you did.
 Ensure there is a reasoned rationale (evidence) for any decision recorded.
 Ensure notes are accurately dated, timed, and signed, with the name printed alongside the entry.
 Write the notes, where possible, with the involvement and understanding of the patient or
caretaker.
 Errors should be corrected by putting a single line through the incorrect statement and signing and
dating it.
 Follow the SMART model (Specific, Measurable, Achievable, Realistic and Time-based) or similar
when planning care
 Write up notes as soon as possible after an event and, by law, within 24 hours, making clear any
subsequent alterations or additions
 Do not include jargon, meaningless phrases (for example 'slept well'), offensive subjective
statements.
 It must be clear what was originally written and why it was changed, therefore correction fluids
should not be used.
 The NMC's position on abbreviations is that they should not be used (NMC, 2002c). e.g. 'PT' could
mean patient, physiotherapist or part time; 'BD' could mean twice or brought in dead.

NURSING 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 a 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.

IMPORTANCE OF REPORTS
 Good reports save duplication of effort and eliminate the need for investigation to learn the facts in
a situation.
 Full reports often save embarrassment due to ignorance of situation.
 Patients receive better care when reports are thorough and give all pertinent data.
 Complete reports give a sense of security which comes from knowing all factors in the situation.
 It helps in efficient management of the ward.

CRITERIA FOR GOOD REPORTS

 Reports should be made promptly if they are to serve their purpose well.
 A good report is clear, complete, concise.
 If it is written all pertinent, identifying data are include – the date and time, the people concerned,
the situation, the signature of the person making the report.
 It is clearly stated and well organized for easy understanding.
 No extraneous material is included.
  Good oral reports are clearly expressed and presented in an interesting manner. Important points
are emphasized.

TYPES OF REPORTS
1. Oral reports
 Oral reports are given when the information is for immediate use and 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. Written reports
 Reports are to be written when the information to be used by several personnel, which is
more or less of permanent value, e.g., day and night reports, census, interdepartmental
reports, needed according to situation, events and conditions.

HOW TO WRITE A BETTER REPORT

1. Before anything can be written clearly, it must be clear in one’s own mind.
2. Reports, lacking facts, may be biased or worthless.
3. Conciseness, accuracy and completeness are essential to good reports.
4. It is better to write several reports than one when there is more than one main subject upon which
to report
5. Use terminology in keeping with the nature of reports:
 Short, simple, commonly used words for nontechnical reports.
 Scientific terms when issuing reports to professional personnel.
 Specific rather than general words
 Use a single meaningful term rather than phrases.
6. Observes mechanics of good writing.
 Use goods sentences and paragraphs
 Observe margins
 Spell properly; avoid abbreviation except in clinical charting.
 Use correct pronoun
 Don’t forget punctuation
 Be neat
7. Write report in a conversational manner.
8. Date reports
9. If report is typed by someone else, check it before signing it.

NURSE RESPOSIBILITY FOR RECORD KEEPING AND REPORTING

 The patient has a right to inspect and copy the record after being discharged
 Failure to record significant patient information on the medical record makes a nurse guilty of
negligence.
 Medical record must be accurate to provide a sound basis for care planning.
 Errors in nursing charting must be corrected promptly in a manner that leaves no doubts about the
facts.
 In reporting information about criminal acts obtained during patient care, the nurse must reveal
such information only to the police, because it is considered a privileged communication.

CHARACTERISTICS OF GOOD RECORDING AND REPORTING:

 1. Accuracy: Information should be correct to prevent serious mistakes. Use of correct spelling and
the institutions accepted abbreviation and symbols ensure accurate interpretation of information. It
should be always complete with accurate signature. Do not use nick names.
2. Conciseness: Use a few words as possible to give the necessary information.
3. Thoroughness: Even a concise record or report must contain complete information.
4. Up to date: Recording should be done on time. A definite time and routine for the reporting make
more time and routine for the reporting makes more efficient management. Delay in recording can
result in serious omissions and delay the work.
5. Organization: Communicate all the information in a logical format or order.
6. Confidentiality: The information should be confidential.
7. Objectivity: Presentation of facts not personal feelings, to give true picture.

Maintaining good quality records and reports has both immediate and long-term benefits for staff. In the
long term it protects individuals and teams from accusations of poor record-keeping, and the resulting drop
in morale. It also ensures that the professional and legal standing of nurses are not undermined by absent
or incomplete records if they are called to account at a hearing.

FIELD HEALTH SERVICE INFORMATION SYSTEM (FHSIS)

 It is a network of information
 It is intended to address the short term needs of DOH and LGU staff with managerial or
supervisory functions in facilities and program areas.
 It monitors health service delivery nationwide.

OBJECTIVES OF FHSIS
 To provide summary data on health service delivery and selected program accomplishment
indicators at the barangay, municipality/ city, and district, provincial, regional and national levels.
 To provide data which when combined with data from other sources, can be used for program
monitoring and evaluation purposes.
 To provide a standardized, facility-level data base that can be accessed for more in-depth studies.
 To minimize the recording and reporting burden at the service delivery level in order to allow more
time for patient care and promote activities.

IMPORTANCE OF FHSIS
 Helps local government determine public health priorities.
 Basis for monitoring and evaluating health program implementation.
 Basis for planning, budgeting, logistics and decision making at all levels.
 Source of data to detect unusual occurrence of a disease.
 Needed to monitor health status of the community.
 Helps midwives in following up clients.
 Documentation of RHM/PHN day to day activities.

COMPONENTS OF FHSIS
1. Individual Treatment Record (ITR)
2. Target Client List (TCL)
3. Summary Table
4. The Monthly Consolidation Table (MCT)

INDIVIDUAL TREATMENT RECORD (ITR)

 The fundamental building block or foundation of the Field Health Service Information
System is the INDIVIDUAL TREATMENT RECORD.
 This is a document form, or piece of paper upon which is recorded the date, name,
address of patient, presenting symptoms or complaint of the patient on consultation
and the diagnosis (if available), treatment and date of treatment.

TARGET CLIENT LIST (TCL)

 The Target Client Lists constitute the second “building block” of the FHSIS and are
intended to serve several purposes
 First is to plan and carry out patient care and service delivery. Such lists will
be of considerable value to midwives/nurses in monitoring service delivery to
clients in general and to groups of patients identified as “targets” or “eligibles”
for one or another program of the Department
 The second purpose of Target Client Lists is to facilitate the monitoring and
supervision of service delivery activities.
 The third purpose is to report services delivered.
 The fourth purpose of the Target Client Lists is to provide a clinic-level data
base which can be accessed for further studies

TARGET CLIENT LISTS TO BE MAINTAINED IN THE FHSIS

1. Target Client List for Prenatal Care
2. Target Client List for Post-Partum Care
3. Target Client List of Under 1 Year Old Children
4. Target Client List for Family Planning
5. Target Client List for Sick Children6.  NTP TB Register
6. National Leprosy Control Program Form 2-Central Registration Form

SUMMARY TABLE
 The Summary Tables is a form with 12-month columns retained at the facility (BHS)
where the midwife records monthly all relevant data. The Summary Table is composed
of:
1. Health Program Accomplishment this can serve as proof of accomplishments
to show LGU officials whenever they visit the facility.
2. Morbidity Diseases the source of ten leading causes of morbidity for the
municipality/city. This summary table will help the nurse and MHO to get the
monthly trend of diseases.

THE MONTHLY CONSOLIDATION TABLE (MCT)

 The Consolidation Table is an essential form in the FHSIS where the nurse at the RHU
records the reported data per indicator by each BHS or midwife.
 This is the source document of the nurse for the Quarterly Form.
 The Consolidation Table shall serve as the Output Table of the RHU as it already
contains listing of BHS per indicator.
FHSIS REPORTING
These are summary data that are transmitted or submitted on a monthly, quarterly and on
annual basis to higher level. The source of data for this component is dependent on the
records.

THE MONTHLY FORM

 Program Report (M1)

o The Monthly Form contains selected indicators categorized as maternal care,
child care, family planning and disease control.
 Morbidity Report (M2)
o The Monthly Morbidity Disease Report contains a list of all diseases by age
and sex. The Midwife uses the form for the monthly consolidation report of
Morbidity Diseases and is submitted to the PHN for quarterly consolidation.

THE QUARTERLY FORM

 Program Report (Q1)
o The Quarterly Form is the municipality/city health report and contains the
three-month total of indicators categorized as maternal care, family
planning, childcare, dental health and disease control
 Morbidity Report (Q2)
o The PHN uses the form for the Quarterly Consolidation Report of
Morbidity Diseases to consolidate the Monthly Morbidity Diseases taken
from the Summary Table.

THE ANNUAL FORMS (A-BHS, A1, A2 & A3)

 ABHS Form is the report of midwife which contains data on demographic,
environmental and natality.
 The report of nurse at the RHU/MHC are the Annual Form 1 which is the report on vital
statistics: demographic, environmental, natality and mortality.
 Annual Form 2 is the report that lists all diseases and their occurrence in the
municipality/city. The report is broken down by age and sex.
 Annual Form 3 is the report of all deaths occurred in the municipality/city. The report is
also broken down by age and sex.

FLOW OF REPORT

OFFICE PERSON RECORDING FORMS FREQUENCY SCHEDULE OF

TOOLS SUBMISSION
BHS MIDWIFE ITR MONTHLY MONTHLY EVERY 2ND WEEK OF
TCL FORM THE SUCCEEDING
ST (M1&M2) MONTH

A-BHS FORM ANNUALLY EVERY 2ND WEEK OF

 JANUARY
RHU PHN ST QUARTERLY QUARTERLY EVERY 3RD WEEK OF
MCT FORM THE 1ST SUCCEEDING
(Q1&Q2) QUARTER

ANNUAL EVERY 3RD WEEK OF

FORM JANUARY
-A1
-A2
-A3

Reference:
1. Monina H. Gesmundo, RN RM MAN, (2010). The Basics of Community Health Nursing; A study Guide for
Nursing Students and Local Board Examinees. Philippines
2. Araceli S. Maglaya, (2004). Nursing Practice in the Community (4th ed). Philippines
3. DOH, (2008). Public Health Nursing in the Philippines. Philippines
4. https://www.slideshare.net/jasleenbrar03/nursing-records-reports
5. https://www.slideshare.net/MarkFredderickAbejo/community-health-nursing
6. https://www.scribd.com/document/434125266/Records-in-Family-Health-Nursing-Practice-docx
7. https://www.nursingpath.in/2019/02/records-and-reports.html