record and report.pptx

record

1. RECORDS AND REPORTS

2. RECORDS DEFINITION: Records are the memory of the internal and external transactions of an organization. Records contain a written evidence of the activities of an organization in the form of letters, circulars, contracts , vouchers , minutes of meeting, books of account etc. [ S.L.Geol, 2001 ]

3. DEFINITION (CONTND…….) It is a written communication that permanently documents information relevant to management or any organization . [ Sr. Mary lucita ]

4. PRINCIPLES OF MAINTAINING RECORDS: Specific purpose should be clearly understood. Items on forms and in registers should be conveniently grouped so as to make their completion as easy as possible .

5. PRINCIPLES OF MAINTAINING RECORDS: Follow SMART formulae. The wording should be easily understood, and where doubt instructions to facilitate interpretation should be included . Every effort should be made to keep records up to dated, accurate and signed. 5

6. Principles of maintaining records (cont…) Provision for periodic review of all records to ensure that they keep pace with the changing needs of the programme. Adequate supply of stationery to permit records to be maintained Record to be maintained on the proper forms and in the proper registers at all times. 6

7. Principles of maintaining records (contnd…) Appropriate equipments to operate a filing system which is simple and safe and requires the minimum possible time should be made available. Adequate, safe, fireproof storage arrangements 7

8. CHARACTERISTICS OF GOOD RECORDING Accuracy Consistent Thoroughness/complete Up to date Organized Specific 8

9. Communication Aids to diagnosis of problem Documentation of continuity Research Legislative use PURPOSE OF KEEPING RECORDS:

10. Prevents duplication of services and helps follow up services effectively. Helps to evaluate the progress. Organization of work PURPOSE OF KEEPING RECORDS 4/27/2018 ANU JAMES 10

11. GUIDELINES FOR RECORD KEEPING be based on fact, correct and consistent be written as soon as possible after an event has happened be written clearly and in such a way that the text cannot be erased . 11

12. GUIDELINES FOR RECORD KEEPING be accurately dated, timed and signed, with the signature . be written in such a way that any alterations or additions are dated, timed and signed, so that the original entry is still clear not include abbreviations, meaningless phrases, irrelevant and offensive statements 12

13. IMPORTENCE OF RECORDS IN HOSPITAL, COMMUNITY AND HEALTH AGENCY.

14. Serve the history of the client Assist in continuity of care Evidence to support if legal issues arise Assess health needs, research and teaching.

15. Importance of Records in Hospital For doctors Serve the guide for diagnosis, treatment, follow-up and evaluation. Indicate progress and continuity of care. Self-evaluation of medical practice Protect doctor in legal issues Used for teaching and research

16. 3 . For the nurses: Document nursing service rendered Shows progress Planning and evaluation of service for future improvement Guide for professional growth Judge the quality and quantity of work done Communication tool between nurse and other staff involved in the care.

17. 4 . For authorities: Statistical information Administrative control Future reference Evaluation of work in terms of quality, quantity and adequacy. Help supervisor to evaluate service Guide staff Legal evidence of service render by each employee Provide justification of expenditure of funds.

18. REPORTS 4/27/2018 ANU JAMES

19. REPORTS A report is usually a piece of factual writing , based on evidence , containing organized information on a particular topic . Reports can be oral or written depending upon the mode of presentation . A report is a summary of activities or observations seen, performed or heard. -Potter and Perry

20. 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.

21. DEFINITION Reports may refer to specific events, occurrence, or subject and may be communicated or presented in oral or written form [ Basvanthappa BT2009 ] 21

22. PURPOSES Report is an essential tool to communication To show the kind and amount of services rendered over a specific period. To illustrate progress in goals. As an aid in studying health condition. As an aid in planning. To interpret the services to the public and to the other interested agencies.

23. CRITERIA FOR A GOOD REPORT made promptly. clear, concise, and complete. All important data to be included-the date and time, the people concerned, the situation, the signature of the person making the report.

24. CRITERIA FOR A GOOD REPORT It is clearly stated and well organized. Important points are emphasized. In case of oral reports they are clearly expressed and presented in an interesting manner.

25. TYPES OF REPORTS Oral report Written report 24 hours report Census report Birth and death report Incidental report change – of – shift report transfer report  legal report

26. ORAL REPORTS Summary of event, observation or situation by word of mouth is called oral reporting. An oral report is simple and easy way to present . It may communicate an impression or an observation .

27. ADVANTAGE AND DISADVANTAGE OF ORAL REPORT immediate feedback is possible Do not add to the permanent records of the organization. needs to comprehend quickly  as and when these are presented. May be encumbered with irrelevant facts and overlook important ones. Cannot be referred to again and again  Have less Professional value.

28. WRITTEN REPORTS A written  document describing the findings of some events or observation is called written reports written reports are always preferred as they enjoy several advantages over the oral ones.

29. ADVANTAGE AND DISADVANTAGE OF WRITTEN REPORT immediate feedback is not possible. Contribute to the permanent records of the organization. can ponder over these reports and understand its own pace. Are more accurate and precise as the writer will be careful in putting down the facts in writing. Can be edited ,reviewed , stored and retrieved. Have more professional value.

30. NURSES RESPONSIBILITY IN RECORD KEEPING AND REPORTING It is the responsibility of nurse to make sure records and reports to be accurate , complete, current , organized and make confidential.

31. Keep under safe custody. No individual sheet should be separated. Not accessible to patients and visitors. Strangers is not permitted to read records. Handed carefully, not destroyed. NURSES RESPONSIBILITY IN RECORD KEEPING AND REPORTING

32. Nurses should make sure that record and report be written as soon as possible after an event has happened be written clearly and in such a way that the text cannot be erased be accurately dated, timed and signed, with the signature printed alongside the first entry

33. cont.. be written in such a way that any alterations or additions are dated, timed and signed, so that the original entry is still clear not include abbreviations, meaningless phrases, irrelevant and offensive statements Never sent outside of the hospital without the written administrative permission.