Records and reports

records and reports in community

1. RECORDS & REPORTS

PRESENTED BY:
MS. KAVITA PAL
M.SC.(N)
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2. DEFINITION:
* Presenting the facts, data,
figures and other information in
writing is called records, means
record is the written presentation
of information.

3. A record is a clinical, scientific ,
administrative and legal document
relating to the nursing care given
to individual, family or community.

4. PURPOSES:
•Provides documentation of the services
that have been rendered and supplies
data that are essential for programme
planning and evaluation.
•To provide the practitioner with data
required for the application of
professional services
•Records are tools of communication
•Shows the health problem in the family
and other factors that affect health.

5. •A record indicates plans for future.
•It provides baseline data to estimate the long-
term changes related to services.
•It provides an opportunity for evaluating the
nursing situation in the family.
•Help to organize the work and saves the time.
•Useful in conducting research.
•It acts as an instrument of Health Education.
•It reveals the essential aspects of service in
such logical order so that the new staff may be
able to maintain continuity of service to
individuals, families and communities.

6. Records : Categories:
•Records to be kept at health centers
•Records to be kept with the patient or
individuals.

7. Records to be kept at health
centers are:
•Family folders
•Mother and child health card
•Medicine distribution cards
•Family welfare records
•Treatment and referral records
•Vital events records
•General Information record
•Others

8. Records to be kept with
patients and mothers:
•Health record of school going child
•Infant health card, Maternal card
•TB patient card,
•Individual health care

9. Guidelines for recording:
1. Clear, appropriate and readable.
2. Real and based on facts.
3.Abbreviations and short form can be used in
records but these short forms should be
generally acceptable and standard.
4.Sentences used in records, should be short
and clear.
5.Paying special attention to numbers and
statistics, is essential.
6.It is necessary that the person filling the
records should sign record with time and
date.

10. TYPES OF RECORDS:
•CUMULATIVE OR CONTINUING
RECORDS
•FAMILY RECORDS

11. Guide to secure information:
•Explore the problems, assuring privacy while
securing information.
•Not to force information.
•Ask question in a friendly, definite and direct
manner, e.g. About diet, vaccination.
•After every visit, make relevant notes of visit as
such as purpose, what was done, attitude of family,
plan for next visit and any referrals.

12. FILLING OF RECORDS:
•Alphabetically
•Numerically
•Geographically and
•With Index cards.

13. REPORTS
•Are oral or written exchanges of
information shared between caregiver or
workers in a number of ways.

14. Purposes:-
1.To show the kind and amount of services
rendered over a specific period.
2.To demonstrate progress in reaching the
goals.
3.Serve as an aid in studying the health
condition.

15. 4. Help in interpretating the services to the
public and other agencies.
5. To provide legal protection in case of
litigation.

16. Types of reports:
•VERBAL
•WRITTEN REPORT

17. Guidelines for reporting:
•A general method or outline of writing the report
should be prepared before actually writing report.
•As far as possible, printed forms should be used
for writing the report.
•It is necessary to collect all the information and
material to make the report complete.
•Style of report writing should make it easy to
understand.
•Report should be arranged in such a manner that
essential information can be retrieved easily.

18. Guidelines for reporting:
•Important information should be underlined
or expressed in a specific manner.
•Presentation of report should be attractive
and the important points should be stressed.
•Report should be comprehensive, factual
and based on supervision and actual
information.
•Wording and vocabulary of report should be
simple.

19. Precautions:
•These should be kept carefully a clean place.
•These should be protected against mice,
termites and insects etc.
•Good filing system should be developed for the
records and reports.
•These should be easily available on time.
•Confidential record and report should be
shown to authorize persons only.
•These should be kept only at the definite
place.