Records and reports

Record & Reports for Nursing.. In this slide Yo will see: Introduction, Relation of records and reports, records, type of records, design of records, records related to community health nursing, types, uses of reports, essential requirements of records & reports, Preparation and maintenance of records and reports, guidelines while preparing records, guidelines while preparing reports, maintenance of records and reports.

1. RECORDS AND REPORTS Rajdip Majumder Tutor, Institute of Nursing, Brainware University

2. INTRODUCTION Records and reports are the good tools of communication in any organization to function efficiently. Information are transmitted from downward to upward and from upward to downward. Nurses as a member of the health care team communicate information about the client’s condition through records and reports among the health care providers.

3. RELATION OF RECORDS AND REPORTS Both are mutually interdependent. Report can prepared on the basis of records. Similarly report can be presented as records. Record is always in the written form while report can be oral as well as written form. Report especially oral report, can be forgotten while record can be preserved for long time. Despite of being literally different, record and report are synonymous and interrelated, also they are the essential and important component of community health, management and nursing.

4. RECORDS

5. RECORDS Records are the presentation of facts, figures, date and other information in writing. A record is a permanent written presentation of information. In health care setting, a record is a clinical, scientific, administrative and legal document relating to nursing care given to the individual, family and community.

6. TYPES OF RECORDS It can be seen in various forms: Periodically Unit based S ubject based Collection place based

7. Periodically Temporary records: These are the casual or daily records. Permanent records: these are cumulative or continuing records. These are the students health records, once made and carried out to the next standard about health information of the students like immunization, weight, height and other health check up every year on the same card. It is possible to review the total history of the child/individual and evaluate the progress over a long period.

8. 2. Unit based It includes: Individual records: includes individual health card. Family record of family folder Community record: records of health problem of the community National health program records.

9. 3. Subject based It includes: Medical and nursing records pertaining to the treatment and medicine records. Economical records: financial structure of family and village. Social records: records of social structure. Political records.

10. 4. Collection place based records It includes: Collected at institutions. Ex: records of hospital and health center . Records to be kept with individual. Ex: Immunization card and disease card.

11. DESIGNING OF RECORDS FOLDER TYPE: It is a broad card which can be folded into many parts. 8 or 10, some pages kept blank for future entries. FILE TYPE: A file is maintained for each patient. The outer part of the file is usually printed summarizing information. The periodical data is entered in separate papers and inserted into the file. The file type records are usually maintained by in the hospital for the patient. ENVELOPE TYPE: The file type when closed on 3 sides and kept open on one side. The data is entered on separate papers, tagged together and inserted into envelope.

12. RECORDS RELATED TO COMMUNITY HEALTH NURSING This type of records can be divided into 2 categories: Records to be kept in health centers Records to be kept with the patients/ individuals.

13. a. Records to be kept in health centers Family folder: this includes family, its constituent, structure and individual card. Mother and child health card: these can be part of family folder. They include antenatal card or postnatal card, immunization card, infant card, pre-school child cards. Medicine distribution card: this includes distribution record of iron and folic acid tablets, Vitamin A solution and other medicine. Family welfare records: these includes records of eligible couples, family planning records, MTP records and other related records.

14. a. Records to be kept in health centers Treatment and referral records: this includes records related to remedies of health problem, treatment of patients, home nursing, home visiting and referral system. Vital events record: These include information and registration of birth and death records. General information records: this includes records of individual, family, village and maps of community, facts, picture and health information. Other records: these includes attendance register, medicine stock register, meeting records, monthly/yearly report, consumable stock register, movement register, stationary stock register, patient registration record, cumulative register.

15. a. Records to be kept with patients and mothers Through most of the records are prepared by community health nurse or under her guidance and are kept at the health center , but it is more useful to keep some records with the patients and mother. Advantages of this system: saving of time, records are available with mother even if they settle somewhere else, health education, guidance and evaluation of progress. Generally, following records are kept with mothers and patients: Health record of school going child. Infant health card Maternal card TB patient card Individual health card.

16. USES OF RECORDS It divided in 4 categories: For staff nurse/ Community Health Nurses For Doctors For Health Agency For individual

17. 1.For Staff Nurses/ Community Health Nurses Help to plan and implement care to client. Help to evaluate the care and teaching given to the client. Prevent duplication of work. Help to assess the quality and quantity of care given.

18. 1.For Staff Nurses/ Community Health Nurses Protect in case of legal issue. Serves as a guide to the professional growth. Help in auditing the nursing care.

19. 2. For Doctors Guide for diagnosis, treatment and follow-up care. Help in evaluating the services provided. Indicate the progress of the patient and country of care. Useful for doctors in making research and in medical practice.

20. 3. For Health Agency Records are the proof of services provided by each worker. Help in auditing the care provided to clients. Help in administration in assessing the performance of their own institution. Used as an evaluation tool during conferences and meeting. Provides justification of expenditure of funds.

21. 3. For Health Agency Assist in finding out, health problems 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.

22. 4. For individuals Helps to make them aware of their health needs. Serves as a guide for future treatment.

23. REPORTS

24. INTRODUCTION Reports are the verbal or written information shared between the health workers. Reports are summarize the activities and services of nurses and health care workers. A complete and detailed report holds an important place in the health management.

25. TYPES Verbal report Written report

26. 1. Verbal report Verbal report are more convenient when the information are for immediate use. Sometimes in emergency verbal reports are followed by written report later on. Example: Nurse in-charge of patient care reports about the condition of patient care reports about the condition of patient to treating physician telephonically and taking instruction about patient care. Later on she puts in writing.

27. Types of verbal report Report between head nurse and staff nurse during round of head nurse. Report between the members of health team. Reports on accident, mistakes and complaints while changing the shift. Report between student nurse and clinical instructor.

28. Advantages Helps to deal with emergency when time is premium. Helps in implementing proper care of patients on verbal instruction. Provides feedback. Same time, build-up confidence and maintain good IPR among the health professionals. Serve as a primary source of information.

29. D isadvantages 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.

30. 2.Written reports Reports are written when the information has to be used by several persons which is of permanent value. Example of written report are: Day and night report Census Interdepartmental reports Weekly reports Monthly reports Incidental reports Transfer report Legal reports

31. USES OF REPORT Reports give information about the condition of the patients and 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 problem of an area so that an appropriate action can be taken to solve. Used in health planning. Shows the kind and amount of services rendered in a community. Helps in future budget planning. Serves as a legal documents.

32. ESSENTIAL REQUIREMENTS OF RECORS & REPORTS These are the valuable documents and should be filled carefully. Should be complete in all details. Good filling system should be developed for records and reports. Should be easily available on time. Confidential records and reports should be shown to authorized person only.

33. ESSENTIAL REQUIREMENTS OF RECORS & REPORTS Should be written in such a way that minimum clerical work involved. Confidentiality should be maintained as they get legal importance. Should be placed at definite and safe place.

34. PREPARATION & MAINTENANCE OF RECORS & REPORTS Records should be filled properly in systematic way to save time and energy. Filling of records further depends upon the objectives and methods adopted by the health center or hospital. Some of common methods used are: Alphabetically Numerically Geographically Some of the organization use general and specific methods, they may combine the above mentioned technique.

35. GUIDELINES WHILE PREPARING RECORDS Should be clear, appropriate with eligible handwriting. Based on the facts and reality. Short and clear sentences should be used. Only acceptable abbreviations and short forms has to be used in records. Special attention is to be paid to numbers and statistics. Should be filled with royal blue ink as blank ink fades away with time. Person who is filling the records should sign in capital letters.

36. GUIDELINES WHILE PREPARING REPORTS Reports should be written to 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. The style of report writing should be made easy to understand. The style of report writing should be made easy to understand.

37. GUIDELINES WHILE PREPARING REPORTS Vocabulary used in report writing 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 involved the personal feelings. All information and materials is to be collected before writing report. As far as possible printed forms should be used to save time.

38. MAINTENANCE OF RECORDS AND REPORTS Since records and reports have legal implications. It is duty of the nurse in charge of maintaining the records and reports to keep them, under safe custody. Nurse should maintain records and reports immediately after the incident. Written reports should be preserved in a chronological order so that it is easily available when required. Records and reports should be handled carefully to avoid destruction. Records and reports should be protected from mice, insects etc.

39. MAINTENANCE OF RECORDS AND REPORTS Records related to medico-legal cases, dying declaration and will, etc. should be handled carefully for giving witness whenever required . People get facilities and legal protection on the basis of records. In such cases only with the written permission of authorized person, the Xerox copy of the records can be given and entered in the register. Records should be made accurate and there should be no mistake. Medico-legal cases records and reports should be kept under lock and key. For the destruction of absolute records, legally accepted methods should be used.