Maintenence of Records & Reports.pptx

CoHN

1. MAINTENANCE OF RECORDS & REPORTS BY SHIVANGANA CHAUDHARY NURSING TUTOR (COMMUNITY HEALTH NURSING)

2. MAINTENANCE OF RECORDS AND REPORTS Record-keeping is an integral part of nursing and midwifery practice. It is a tool of professional practice and one that should help the care process. It is not separate from this process and it is not an optional extra to be fitted in if circumstances allow. Anything that makes reference to the care of the patient or client is called record.

3. DEFINITION A Record is a permanent written communication that documents information relevant to a client’s health care management. A Record is a clinical, scientific, administrative and legal document relating to the nursing care given to the individual family or community. Reports are oral or written exchanges of information shared between caregivers or workers in a number of ways. A Report is the summary of the services of person or personnel and of the agency.

4. Functions of Good Record-Keeping Community health nurses help in various matters by good record-keeping. Good record-keeping helps in: Improving accountability Helps in patient care decisions Supporting effective delivery of health services Making effective clinical judgments Supports patient care and communications

5. Cont. Promotes the involvement of client in his/her health care Promotes continuity of care Serves as documentary evidence Helps to communicate and share information among members of health care team Promotes early identification of risks and early detection of complications necessary treatment

6. Cont. To evaluate the services and allocate resources To know about the individual, family and community health and nutritional status To elicit the causes of specific mortalities and morbidities Helps in planning and budgeting.

7. Types of Clinical Records There are various types of clinical records used in the field of community health nursing. They are: Handwritten clinical notes (home visit report, individual antenatal, infant, preschooler health record) Hand written or electronic health records (including scanned records) E-mails Official letters from top level health management team.

8. Cont. Laboratory reports and x-rays; printouts monitoring equipment. Anecdotes and occurrence (hand written/electronic) reports and statements. Photographs Audio-visual media, e.g. Audio and video tapes, digital recordings, cds and dvds . Tape-recordings of telephone conversations. Text messages.

9. Some of the manual records and registers maintained by the CoHN RECORDS Newborn health record Preschool health record Immunization record Antenatal health record Postnatal health record Morbidity record (TB, hypertension, heart disease, diabetes, etc.)

10. Community health nurse maintains the "register of all activities" that are carried out by different categories health professionals. Some of them are: Staff nurse/ANM Nurse report book ARV/ASV injection register TT injection register AN clinic register PN clinic register IP referral register RTI/STI clinic register IUD register Under 5 clinic register Laundry register

11. Cont. School health program Student health appraisal register Referral slip and follow-up register Home visit register Monthly activity report

12. Registers maintained by village health nurse Family and eligible couples register Mother care register Child care register Vital events/VPD surveillance register Minor ailments treatment register Referral register Drug stock register HSC activities reporting register HSC consolidation register NRHM related activities register.

13. Registers maintained by male health worker- HSC Family register Disease surveillance register Epidemic prevention activity registers Program register School health register Inspection register Drugs, consumables/equipment register Bimonthly report register and diary Birth and death issue register

14. Cont. Tobacco control activity related registers IDSP activities related reports (residual chlorine and H.S monitoring) disease surveillance register ADD/cholera register Register of sanitation Register of vital statistics in each panchayat Enforcement of health related acts. Dangerous and offensive trade register Weekly review register Report on inspection and case sheets.

15. Roles of community health nurse in writing manual record or maintaining electronic record Be written clearly, legibly in non-erased material and must be dated with time and signature. The signatory's name designation/role must be written in the record. Be prompt in recording as soon as possible after an event has occurred. If not, the reasons for the delay should be mentioned. Records must be factual, complete, consistent, accurate consecutive. Avoid complicated jargonUse only internationally accepted abbreviations or follow the organizational policy for internal communication Record only relevant and useful information

16. Cont. Do not overwrite or use erasers or fluid to cancel errors. It is better to strike the word to cancel mistake and initial underneath with sign and date of the person It should be visible, readable when photocopied or scanned Keep records securely and confidentially. The information obtained and only shared appropriately and lawfully Store under lock and key Preserve as per the time mentioned in the institutional policy Records must not be in access to unauthorized persons Care must be taken to secure confidentiality of electronic records; specifically when it is shared or transferred.

17. Cont. Retention and disposal of records Follow the organizational policy for retaining and disposing of the records. Records-auditing Yearly once or as per the policy of the institution, audit process carried out to assure the quality of record keeping for further planning.