RECORDS AND

REPORTS
INTRODUCTION
 Records and reports are the means of
communication between health workers and
their clients.
 Records and reports are a practical and
indispensable aid to the doctor, nurse and
paramedical personnel in giving the best
possible service to their clients.
RECORDS
 DEFINITION:
 Record is piece of information or evidence
constitutive account of something that has
occurred preserved in writing.
Records are means of communicating
essential facts in writing in order to maintain
a continuous history of events over a period
of time.
 PURPOSES:
To have a record of patient particulars for
reference at all times.
It helps the staff to understand the
comprehensive needs of the patients and their
problems.
It helps to coordinate the work of nursing staff
with other personnel.
It helps in the guidance of staff and students
when planned records are utilized as an
evaluation tool during conferences.
It helps the administrator to assess the health
assets and need of the community.
It helps in making studies for research.
It helps in planning budget and provides
statistical data.
It provides justification of expenditure of funds.
It serves as legal documents and protects the
organization in the event of legal questions.
It serves as a legal evidence for the services
rendered by each employee or worker.
In a training institution, the records are used as
reference for teaching.
It helps to avoid errors or overlaping of work.
 PRINCIPLES:
 Since the clinical record is a legal document, it
is essential that they should be written clearly,
accurately, appropriately and legibly.
 The individual who writes them should sign all
entries.
 Care to be taken not to make any error on the
records. If anything is crossed out, it should be
dated and initialed.
 All records should be written with black ink or
typed for better legibility.
 Use only standard abbreviations.
 Records should be written in chronological
order as to date and time.
 Records are written continuously with no blank
spaces. If any space is left out, it should be
crossed out dated and signed.
 Lengthy corrections of records are written as
amendments.
 Each page of the record should be properly
identified with the name, age, IP no, date etc.
 Record should be truthful, brief and complete.
 It should include all the services given to the
patients, the observations made on the patient
from day to day
 TYPES OF RECORD
A) RECORDS IN NURSING EDUCATION:
 Students record:
- Application forms and other reports,
recruitment, selection and appointment of
students.
- Record of each students for the theory /
practical hours of experience in each subject.
- Progress report for each student in
examination, internal assessment and awards
etc.
- Health records for each students
- Leave records
- Cumulative record.
 Faculty records:
- Personal file for each faculty includes copy of
the letter of appointment, joining letter,
application form or resume and other relevant
letter as per the policy of the management.
- Job description
- Record of faculty members educational
qualifications, previous experience, any short
term courses attended, membership in
professional activities, publication,
participation in conferences and seminars
- Leave records and health records
- Service book
- Performance appraisal.
 General records of college/school:
- Philosophy, aims and objectives of the institution.
- Curriculum of the college/school.
- Prospectus for college/school.
- Written policy of the school in various areas i.e,
library, A.V aids, discipline, hostel policy etc.
- Budget proposal and allotment to various
department.
- Inward and outward register
- Inventories of stock
- Records and reports of various committees
- Admission records of students
- Reports of state council.
- Reports of INC
- Affiliation and continuation letters and records
of the university.
- Rules and regulation for the university
examination.
- Records for the extra curriculum activities.
- Records of important landmark of the
college/school.
B) RECORDS IN NURSING SERVICE ADMINISTRATION
 Nursing administrative records: These are concerned with
hospital and also includes personnel service records of each
individual in service.
o These records can be maintained all the unit level and
submitted to the nursing superintendent. These records are:
- Number of nurses in the unit/ward/department and rotation
plan.
- Weekly duty schedule/monthly duty schedule of nursing
staff.
- Record of staff development programme including
orientation, in-service education programme.
- Records of performance of nursing staff members.
- Annual confidential reports of the staff nurse.
- Dead stock register of the unit for medicine,
linen, equipment and supplies.
- Performance appraisal, self-evaluation, peer
group, evaluation records and anecdotal
records.
o Nursing superintendent has to keep certain
records readily available:
- Hospital hand book.
- Hospital brochure.
- Hospital annual report.
- Philosophy, aims and objectives of the hospital.
- Policies of the hospital for recruitment/
selection/ promotion and other area.
- Total number of nurses on the roll.
- Hospital map and physical layout of the various
department.
- Confidential records of the nursing personnel.
- Staff development records.
- Disciplinary action records.
- Records of various committees, meeting, memo,
notices etc.
- Students rotation plan.
- Visitors book.
- Check list of disaster management.
 Clinical records: it serves as evidence to the
patient that his care is being intelligently
managed and recorded.
o Admission record :-
- Is important for legal and diagnostic point of
view.
- It includes a full description of his/her symptoms
both related and unrelated to the condition for
which he/she was admitted.
o Nurses notes :-
- Nursing notes should describe accurately the
patient condition and record the nursing care
given to the patient.
C) RECORDS IN COMMUNITY :
Health records in the community refers to forms
on which information about an individual and his
family is noted.
 Family health records:
o According to the age of family member –
- New born care
- Infant card
- Toddler card
- Adult card
- Elderly card
- Mother child link card
o According to the health services provided in
the family –
- Antenatal care card
- Labour record card
- Postnatal care card
- Person with illness
• Tuberculosis record, diabetic record,
hypertension record
- Drug addicts or alcoholics record
- Any other chronic diseases care record
- Immunization record
o These records are in the form of folders, file,
cards, charts and register.
REPORTS
 DEFINITIONS:
 Reports are the effective methods of
communication among the member of the
team or group.
 Reports are oral or written exchanges of
information shared between care givers or
workers in a number of ways. It is usually
written daily, weekly, monthly or yearly.
 PURPOSES:
• To show the kind and amount of services
rendered over a specified period.
• To illustrate progress 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.
TYPES OF REPORTS
A) REPORTS IN HOSPITAL:
 HANDOVER REPORT /CHANGE OF SHIFT REPORTS:
o These may be given orally in person by audiotaping,
recording or during rounds at the clients bedside.
o Points to be kept in mind while giving reports:
- Give only essential information about client.
- Identify clients needs/ problems and other related
causes.
- Continuously review on-going discharge plan
- Describe instruction given in teaching plan and
client’s responses.
- Evaluate results of nursing care or medical care.
- Be clear on priorities to which on coming staff must
attend.
 TRANSFER REPORT:
o A transfer report involves communications of
information about clients from the nurse on
sending unit to the nurse on the receiving unit.
o Following information should be given while
transfering:
- Client’s name, age, sex, doctor’s unit and
medical diagnosis.
- Summary of health status
- Current nursing diagnosis /problem and care
plan.
- Any critical assessment or interventions to be
completed shortly.
- Needs for any special equipments for patient
care.
 INCIDENT REPORT:
o Nurse must understand the purpose of incident
reports and the correct way to report information.
o Following points to be kept in mind:
- The nurse who witnessed the incident should file
the report.
- The nurse describes in concise what happened
specifically .
- The nurse does not interpret or attempt to explain
the cause of the incident.
- Any measures taken by nurse/doctors are reported.
- Report should be submitted promptly to the
appropriate authority.
- Nurse should never make photocopy of the incident
report.
B) REPORTS IN COLLEGE /SCHOOL OF
NURSING:
- Data related to students, staff and the faculty.
- Data related to physical facilities, clinical
facilities, administration and the curriculum.
- Any change in the college / school programme
than the previous report.
- Proposals and plans for future development.
- Problems encountered.
- Recommendations .