Records & reports

Records & reports/UNIT 8/CHN/GNM/KSDNEB

1. RECORDS & REPORTS GNM / CHN / UNIT 8 1 BCCN

2. INTRODUCTION Records and reports are the good tools of communication in any organization to function efficiently. Information's are transmitted from downward to upward and from upward to downward. Effective communication is vital to the client care among the health professional. Nurses as a member of the health care team communicate information's about the client's condition through records and reports among the health care providers. Client depends on nurses to communicate about their health problems to the doctors and other concerned with him for best quality of care. It is essential for all the members of health care team to have accurate practice of maintaining records and reports. 2 BCCN

3. RECORDS Records are the presentation of facts, figures, date and other information's in writing . “ A record is a permanent written presentation of information” In health care setting: A record is a clinical, scientific, administrative and legal documentation to the nursing care given to the individual, family and community Records are practical & Indispensible tools of the doctors, nurses and other paramedical staff to plan and deliver the best possible care to the clinic 3 BCCN

4. TYPES OF RECORDS PERIODICAL RECORDS: Temporary Records ( casual /daily records) Permanent Records ( Cumulative / continuing records) Egs 1 : Students health records ( with immunization, height , weight and other health check –up every year on same card . It helps to review the total history of child/individual and evaluate progress over a long period) Egs 2 : Cumulative Records ( Learning experience and improvement through out a course & records of what they learnt) 2. UNIT BASED RECORDS : Individual records includes individual health record Family record of family folder Community records National Health Program Records BCCN 4

5. 3. SUBJECT BASED RECORDS: Medical & nursing records pertaining to the treatment & Medicine records Economical records- financial structure of family & village Social records- records of social structure Political records 4. COLLECTION PLACE BASED RECORD Records of hospital & health centers Immunization card, disease card BCCN 5

6. DESIGNING OF CARDS/RECORDS 1. FOLDER TYPE : It’s a broad card which can be folded into many parts.8 or 10, some pages kept blank for future entries 2. FILE TYPE: A file is maintained for each patient . Outer part printed for summarizing information Periodical data entered in separate papers and inserted into file. File type records maintained in hospital for patients 3. ENVELOP TYPE File type closed on 3 sides and kept on one side Data entered on separate paper , tagged together and inserted into envelope BCCN 6

7. RECORDS MAINTAINED HOSPITALS, HEALTH CENTERS AND AT NURSING EDUCATIONAL INSTITUTE HOSPITAL RECORDS Admission & discharge register of patients Treatment register Laboratory investigation register Staff attendance and leave register Equipment stock register Patient day and night report register Linen register ,Dhobi book and laundry register Medical officer on call duty register Drug indent register and maintenance register Condemnation register Census Register BCCN 7

8. Diet register Complaint register Birth and death register Accounts register Inventory register Bedside chart, vital register Operation register Conferences/meeting register Suggestion register BCCN 8

9. PHC RECORDS General information records Outdoor patients records Treatment and referral records Family welfare records Vital events records ( birth & Death, Stock register for equipment and drugs, medicine distribution register) Mother and child health records ( Antenatal , postnatal and immunization records) Infant & Preschool children record Family folder Other records are: Attendance register, medicine stock register, meeting records, monthly and yearly report register, stationary stock register , patients registration records, depot holder record, daily diary cumulative records, training register. BCCN 9

10. RECORDS AT SUBCENTER LEVEL Mother care register Child care register Program register Daily dairy Review register Stock register Monthly report register Family welfare register Referral register School health register General information register Eligible Couple register BCCN 10

11. RECORDS AT VILLAGE LEVEL Birth and death register Mother care RECORD REGISTER Child care record register, growth chart Immunization register Eligible register Eligible couple register RECORDS IN NURSING EDUCATION PROGRAM Student Record Staff record General school record STUDENTS RECORD Admission application forms Health records Attendance register BCCN 11

12. Leave records Progress reports Internal Assessment Clinical experience record Daily diary Cumulative records Anecdotal records Course plan Unit Plan Clinical rotation plan SNA meeting register TEACHING FACULTY AND OTHER STAFF RECORDS Job description Educational qualification, experience records BCCN 12

13. Progress record Leave record Staff development register Staff meeting register GENERAL RECORDS Inventory register Records of meeting of University Council/University inspection register Dispatch register Indent register Philosophy, purpose and curriculum of college Budget of the college Sports and extracurricular activities Copy of the school/college brochure Various files related to administration BCCN 13

14. RECORDS TO BE KEPT BY PATIENT Health records of School going child Infant health records including immunization Records of antenatal and postnatal mother Records of tuberculosis patients Individual health cards PRINCIPLES OF WRITING RECORDS Records should be written immediately, after an event has occurred Records should be real based on facts , observation, conversation and action Only accepted abbreviation should be used Short and clear sentence to be used Records should be appropriate , accurate and legible Records are valuable legal documents so it should be kept confidential Records should be written with blue ball point ink Uniformity in writing records should be maintained BCCN 14

15. USES OF RECORDS FOR STAFF NURSES/COMMUNITY HEALTH NURSES Help to plan and implement care to the client Help to evaluate the care & teaching given to the client Prevent duplication of work Help to assess the quality and quantity of care given Protect in case of legal Issues Serve as a guide to the professional growth Help in auditing the nursing care FOR DOCTORS Guide for diagnosis , treatment and follow up care Help in evaluating the patient and continuity of care Useful for doctors in making research and in medical practice. BCCN 15

16. FOR HEALTH AGENCY Records are the proof of services provided by each worker Help in auditing the care provided to clients Help the administration in assessing the performance of their own institution . Used as an evaluation tool during conferences & meeting Provides justification of expenditure of funds Assist in finding out, health problem of community unit Legal document for community health activities Assist in determining the need of resources like medicine , equipment and manpower Means of communications between health workers , family and community. BCCN 16

17. FOR INDIVIDUALS Helps to make them aware of their health needs Serves as a guide for future treatment and care RELATION OF RECORDS AND REPORTS Reports are written on the basis of records Reports can be presented as record Records are always in written form, whereas, report can be written as well as verbal Records can be preserved whereas verbal reports can be forgotten Both records and reports are SYNONYMOUS and INTERDEPENDENT Both are important TOOLS of COMMUNICATION, MANAGEMENT in hospital and community health centers and Nursing BCCN 17

18. REPORTS Reports are the verbal /written information shared between the health workers Reports summarize the activities of nurses and health care workers TYPES OF REPORTS Verbal Report Written Report BCCN 18

19. VERBAL REPORT Its convenient for immediate use Emergency verbal reports are followed by written reports later. Verbal reports made about complaints for immediate rectification Types of Verbal Reports: Report between head nurse and staff nurse Report between the members of health team Reports on accident, mistakes and complaints while changing the shift Report between student nurses and clinical instructor BCCN 19

20. Advantages Helps to deal with emergency when time is premium Helps in implementing proper care of patients on verbal instructions Provides feedback Saves time, build-up confidence and maintain good interpersonal relation(IPR) among the health professionals Serve as a primary source of information Disadvantages Possibility of mistakes due to wrong interpretation No proof, personnel can deny what is told No permanent record is present Can result in legal problems Not useful in legal matters BCCN 20

21. WRITTEN REPORTS Reports are written when the information has to be used by several persons which is of permanent value Egs: Day and Night report Census Interdepartmental reports Weekly reports Monthly reports Special reports on unusual incidents Accident reports Evaluation reports Transfer reports Legal reports BCCN 21

22. Uses of reports Information about condition of the patients &day to day progress of patients health Reports are used as an aid in planning patient care In community, reports help in studying the health problems of an area so that an appropriate action can be taken to solve Used in health planning Shows the kind and amount services rendered in a community Helps in future budget planning Serves as a legal document BCCN 22

23. ESSENTIAL REQUIREMENT OF RECORDS AND REPORTS Should be filled carefully Should complete in all details Proper filling system should be developed for records and reports Should be easily available on time Confidential records & reports should be shown to authorized person only Should be written with minimum clerical work involved Confidentiality to be maintained as they get legal importance Should be placed at definite and safe place BCCN 23

24. PREPARATION AND MAINTENANCE OF RECORDS & REPORTS Preparation of Records: Records to be filled properly in systematic way to save time & Energy Filling of records depend on objective & methods adopted by the health center or hospital Some of the methods commonly used are: Alphabetically Numerically Geographically BCCN 24

25. GUIDELINES WHILE PREPARING RECORDS Should be clear, appropriate with eligible handwriting Based on the facts and reality Short and clear sentences Acceptable abbreviations and short forms Special attention on Numbers and Statistics Should be filled with Royal blue ink as black ink fades away with time After filling the records it has to be signed in capital letters by the same person GUIDELINES WHILE PREPARING REPORTS Reports should be writing in such a way that all essential information can be easily retrieved Important information should be highlighted Presentation should be attractive and important points are stressed BCCN 25

26. Style of report has to be made easy to understand Vocabulary used should be simple Reports should be written based on information and supervision Should be presented correctly to avoid mistakes Actual facts should be presented and should not involve the personal feeling All information and material has top be collected before writing report General outline of writing report has to be prepared before writing report Printed forms are preferred to save time BCCN 26

27. MAINTENANCE OF RECORDS AND REPORTS In charge nurse has to maintain records and reports under safe custody due to its legal implication No room should be left for leakage of information Nurse should maintain records and reports immediately after an incident Written records and reports are maintained in chronological order for easy access It has to be maintained carefully to avoid destruction It has to be protected from mice, termites and insects etc Records related to medico-legal cases, dying declaration and will etc has to be handled carefully for giving witness whenever required BCCN 27

28. Record should be accurate without mistake MLC records & reports to be kept under lock and key For destruction of absolute records legally accepted methods to be used People get facilities and legal protection on basis of records . In such cases only written permission of authorized person, xerox copy of records can be given and entered in the register BCCN 28

29. BCCN 29 Thank YOU