ppt - Health care records and reports.pptx

various records and reports used in hospital and community setting

1. COMMUNITY HEALTH NURSING PRACTICE TEACHING BY: POOJA KAJLA MSC (H) NURSING 1 ST YEAR ,STUDENT

2. RECORDS AND REPORTS ATCOMMUNITY LEVEL

3. CONTENT Introduction Definition of record Purpose and Use of records Principles of maintaining records Types of records maintained in the hospital and community. Definition of Report Types of reports Purpose of report Importance of reports features for good report. Precaution during Maintenance of reports Problems during report writing Nurses responsibility for records and reports Current update Summary and conclusion References

4. Introduction All professional persons need to be accountable for the performance of their duties to the public. Since nursing has been considered as profession, nurses need to record their work on completion.

5. RECORD Health records refers to the forms on which information about an individual or family is recorded . Records are special category of documents which are a snapshot history of an activity .

6. Record keeping Is an integral part of nursing and midwifery practice. It is a tool of professional practice and one 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. (Nursing and midwifery council April 2002)  

7. Purpose of keeping records Communication Aids to diagnosis Education Documentation of continuity Research Legal documentation Individual case study  

8. USES OF RECORDS Show the health conditions Prevents duplication of services and helps follow Up services effectively. T o evaluate the care and the teaching In organization of work G uide for diagnosis ,treatment and evaluation of services To indicate progress health assets and needs of the village area    

9. PRINCIPLES OF MAINTAINING RECORDS :   Specificity clarity Categorical Accessibility Freedom of expression Periodical review Adequacy

10. TYPES OF RECORDS in hospital

11. TYPES OF RECORDS IN COMMUNITY SETTING periodical c ollection PLACE BASED subject based unit based IN COMMUNITY

12. 1. PERIODICAL Permanent records (cumulative) Temporary records (casual/daily records)

13. 2. COLLECTION PLACE BASED:   Collected at institutions (records of hospitals) Records to be kept with the individual(immunization cards, disease cards)

14. 4. UNIT BASED RECORDS: Individual (individual health cards) Related to family (family folders ) Related to community (community folders ) National (national health programme records)

15. Records to be kept under health centers family folders MCH cards Antenatal card/ postnatal cards Infant card/ Pre-school child card Medicine distribution card Family welfare records. Treatment and referral records Vital event records General information records

16. To be kept with the Patient kept under supervision of community health nurse Health record of school going children Infant health card Maternal card TB patient card Individual health card Birth and death certificate Inpatient and outpatient slip

17. OTHER IMPORTANT HEALTH RECORDS Daily diary Village record No of trained dais No of eligible couples Community health institutions Anganwadi etc . Schools, post offices, police stations, place of worship Means of transportation and communication Environment conditions  

18. Electronic Medical Records  

19. REPORTS: - These are account or statement describing in detail an event, situation, or like, usually as the result of observation, inquiry, etc. a formal or official presentation of facts .  

20. PURPOSE OF REPORT Communication • To show the kind and amount of services rendered over a specific period. • To illustrate progress • A id in studying health condition. • P lanning . •Interpret the services to the public and to other interested agencies

21. CRITERIA FOR A GOOD REPORT   made promptly. clear , concise, and complete. well organized Important points are emphasized. In case of oral reports they are clearly expressed and presented in an interesting manner. If it is written all pertinent, identifying data are included-the date and time, the people concerned, the situation, the signature of the person making the report.

22.   CLASSIFICATION OF REPORTS Verbal/oral report Written report

23. TYPES OF REPORTS   IN HOSPITAL IN COMMUNITY Change – of – shift reports Transfer reports Incident reports Legal reports Anecdotal reports Monthly, quarterly, yearly or annually reports Evaluatory report  

24. IMPORTANCE OF RECORDS AND REPORTS Assessing the health status data related to various aspects of health and related areas . Assessment and evaluation of work. B asis for formulating present and future plans Tool or medium for health education.

25. PRECAUTIONS DURING MAINTENANCE OF RECORDS AND REPORTS Clear , appropriate and in readable form . Standard abbreviations Short and clear Sentences . protected against termites, rodents and insects. Good filling system kept at definite and appropriate place. Signature of person should be there who had filled the records never change another persons entry . Use a single line to cross out error . Date and time of each entry Do not leave space in between entries . Document all telephone calls that you received .

26. NURSES RESPONSIBILITY IN RECORDING AND REPORTING   Protection from loss   Safeguarding its content Fact A ccuracy completeness Currentness   O rganization

27. MIS (management information system ) Maternal pregnancy tracking system Asha soft Biometric

28. REFERENCE Clement I; Basic Concepts of Community Health Nursing; 2 nd Edition; Jaypee Brothers Medical Publishers (P) LTD; Pp. 140-144 Swarnkar K.; Community Health Nursing (Includes behavioural sciences and personal hygiene); 3 rd Edition; N.R. Brothers Publications ; Pp. 783-85 Basavanthappa BT.;Nursing administration ; 3 st Edition; Jaypee Brothers Medical Publishers (P) LTD; Pp. 384-86

29.   Goel sonu ; Gupta Anil kumar ;Singh Amarjeet ;Hospital administration ; 1 st Edition; Elsevier publication ; pp 370-375 Ministry of Health; Health Care Records - Documentation and Management Available at : http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2012_069.pdf

30. Enlist the various Reports and records by IPHS (Indian Public health standards ) at : Sub centre Primary health centre community health centre