records and reportsin phc.pptx

management

1. Nursing Records and reports

2. Records

3. DEFI N I T I O N Records 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, reports, contracts, invoices, vouchers, minutes of meeting, books of account etc. According to S.L.Geol, 2001 It is a written communication that permanently documents information relevant to a client’s health care management. It is a continuing account of the client’s health care needs According Sr. Mary lucita ]

4. PRINCIPLES OF MAINTAINING RECORDS Specific purpose which should be clearly understood Items on forms and in registers should be conveniently grouped so as to make their completion as easy as possible. The wording should be easily understood, and where doubt is likely to arise, instructions to facilitate interpretation should be included. Records should permit some freedom of expression. Records which are required by the teaching staff should be easily accessible to them. Person responsible for maintaining records should be aware of their particular responsibility and every effort should be made to keep records up to date and accurate.

5. PRINCIPLES OF MAINTAINING RECORDS 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 on the proper forms and in the proper registers at all times. Sufficient number of filing cabinets and appropriate equipments to operate a filing system which is simple and safe and requires the minimum possible time. Adequate, safe, fireproof storage arrangements

6. CHARACTERISTICS OF RECORDS A CC U R A C Y CONSCIOUSNESS THOROUGHNESS UP TO DATE ORGANIZATION C O N F I D E N T I A L I T Y OBJECTIVITY

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 as it is and as the patient and family accepts it. goals towards which means are to be directed. prevents duplication of services and helps follow up services effectively. Helps the nurses to evaluate the care and the teaching Organization of work Serves as a guide for diagnosis treatment and evaluation of services indicate progress Used in research The health assets and needs of the village area

9. TYPES OF RECORDS PATIENTS CLINICAL RECORD INDIVIDUAL STAFF RECORDS WARD RECORDS ADMINISTRATIVE RECORDS WITH EDUCATIONAL VALUE.

10. 1) PATIENTS CLINICAL RECORDS It is the knowledge of events in the patient illness, progress in his or her recovery and the type of care given by the hospital personnel- Scientific and legal Evidence to the patient the his /her case is intelligently managed. Avoids duplication of work. Information for medical and legal nursing research. Aids in the promotion of health and care. Legal protection to the hospital doctor and the nurse

11. PATIENTS CLINICAL RECORDS NURSING ADMINISTRATOR’S RESPONSIBILITY Protection from loss Safeguarding its contents Completeness Responsibility for nurses notes. Legal value of nurses notes. Admission record. Scientific value of the nurses notes Record of order carried out.

12. 2. INDIVIDUAL STAFF RECORDS A separate set of record is needed for staff, giving details of their sickness and absences, their carrier and development activities and a personnel note

13. 3. WARD RECORDS Reducing or increase in beds. Change in medical staff and non nursing personnel for the ward. The introduction and pattern of support.

14. 4. ADMINISTRATIVE RECORDS WITH EDUCATIONAL VALUE Treatments. Admissions. Equipments losses and replacements Personnel performance. Other administrative records

15. TYPES OF RECORDS IN THE DEPARTMENT OF PUBLIC HEALTH CUMULATIVE OR CONTINUING RECORDS FAMILY RECORDS REGISTERS REPORTS

16. 1 . CUMULATIVE OR CONTINUING RECORDS This is found to be time saving, economical and also it is helpful to review the total history of an individual and evaluate the progress of a long period. A cumulative record is a systematic account of information about a student . It is an evaluation tool which presents a comprehensive record of the achievement or otherwise of each student in different aspect-physical academic, moral, social and health.

17. 2. FAMILY RECORDS All records, which relate to members of family, should be placed in a single family folder. Gives the picture of the total services and helps to give effective, economic service to the family as a whole. Separate record forms may be needed for different types of service such as TB, maternity etc. all such individual records which relate to members of one family should be placed in a single family folder.

18. GUIDELINES FOR DOCUMENTATION AND RECORD KEEPING The Nursing and Midwifery Council (NMC 2002) has said that patient and client records should: 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 be written in such a way that any alterations or additions are dated, timed and signed, so that the original entry is still clear be accurately dated, timed and signed, with the signature printed alongside the first entry not include abbreviations, jargon meaningless phrases, irrelevant speculation and offensive subjective statements be readable on any photocopies

19. IMPORTENCE OF RECORDS IN HOSPITAL OR HEALTH CENTERS . INDIVIDUAL AND FAMILY FOR THE DOCTOR FOR THE NURSE FOR AUTHORITIES

20. VALUE AND USES OF RECORDS IN HOSPITAL AND HEALTH CENTRE 1.FOR THE INDIVIDUAL AND FAMILY Records serve to document the history of the client. Records assist in the continuity of care. Records serve as evidence to support or to manage or face the legal questions that arise. Records serve to recognize the health needs and can be used as a research and teaching tool.

21. 2. FOR THE DOCTOR Serves as guide for diagnosis, treatment, follow up and evaluation of services. Indicate progress and continuity of care. Help self evaluation of medical practice. Protect the doctor in case of legal issues. Records may be used for teaching and research.

22. 3. FOR THE NURSE Provide with documentation of services rendered, i.e. shows health condition of the client. Provide data essential for planning and evaluation of services for further improvement. Serve as a guide for professional growth. Enable to judge the quality and quantity of work done. Serve as communication tool between staff and other members involved in care. Indicate plans for the future. For Authorities Provide the management with stati

23. 4. FOR AUTHORITIES Provide the management with statistical information necessary for decision in regard to utilization of resources, planning for administrative control and future references. Help the supervisor evaluate the services rendered, teaching done and a person’s action and reactions

24. RECORD MAINTENANCE IN COMMUNITY SETTING 1.FORMS, CASE CARDS AND REGISTERS. Family record Eligible couple and child register Sterilization and IUD register MCH Card/ register Child Card/ register Birth and death register Sub centers/PHC/clinic register Stock & Issue register Reports of blood test of Malaria and Filaria Malaria parasite positive case register and others

25. 2. DIARIES Diary of (M and F) Diary of HA (M and F) 3. RETURN - Monthly report of HW ( M and F) Complication report of HW (M and F) PHC Monthly report In addition, each organization should maintain: Cumulative records Family records

26. RECORD MAINTENANCE IN HOSPITAL The patient’s clinical record Records of nurses’ observations – Nurses’ Notes Records of orders carried out Records of treatment Records of admission and discharge Records of equipment loss and replacement ( inventory) Records of personnel performance.

27. Nursing R e ports

28. DEFI N I T I O N A report containing information against in a narrative graphic or tabular form, prepared on periodic, receiving, regular or as a required basis. Reports may refer to specific periods, events, occurrence, or subject and may be communicated or presented in oral or written form According to BASVANTHAPPA BT.2009 Reports are oral or written exchanges of information shared between care givers of workers in a number of ways. A report summarizes the service of the personnel and of the agency According to JEAN B. 2002

29. P U RP O S E S Report is an essential tool to communication To show the kind and amount of services rendered over a specific period. To illustrate progress in teaching 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.

30. CRITERIA FOR A GOOD REPORT Made promptly. Clear, concise, and complete. 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. 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.

31. REPORTS IN NURSING EDUCATION Factual data related to the students, staff, clinical facilities, physical facilities, administration and the curriculum Development made in the school programme since the last report. Proposal and plans for future development. Problems encountered Recommendations

32. TYPES OF REPORTS 24 hours reports Census report Anecdotal report Birth and death report Incidental report

33. CLASIFICATION OF REPORTS BASED ON TYPES ORAL REPORTS WRITTEN REPORTS 1. ORAL REPORTS : Oral reports are given when the information is for immediate use and not for permanency. E.g. it is made by the nurse who is assigned to patient care, to another nurse who is planning to relieve her. 2. WRITTEN REPORTS : Reports are to be written when the information to be used by several personnel, which is more or less of permanent value, E.g. day and night reports, census, interdepartmental reports, needed according to situation, events and conditions.

34. REPORTS USED IN HOSPITAL SETTING CHANGE – OF – SHIFT REPORTS TRANSFER REPORTS INCIDENT REPORTS LEGAL REPORTS

35. ADVANTAGES AND DISADVANTAGES OF REPORTS Monitoring operations Controlling Guide decision Employee motivation Performance evaluation It is time consuming. Expensive Reports can be biased Sometimes implementations of the recommendations of a report become unrealistic. Technical reports are not easily understandable

36. NURSES RESPONSIBILITY FOR RECORD KEEPING AND REPORTING Records and reports must be functional accurate, complete, current organized and confidential FACTS ACCURACY COMPLETENESS CURRENTNESS ORGANIZATION CONFIDENTIALITY

37. 1 . F A C T Information about clients and their care must be functional. A record should contain descriptive, objective information about what a nurse sees, hears, feels and smells. 2. ACCURACY A client record must be reliable. Information must be accurate so that health team members have confidence in it. 3.COMPLETENESS The information within a recorded entry or a report should be complete, containing concise and thorough information about a client care or any event or happening taking place in the jurisdiction of manger.

38. 4. CURRENTNESS Delays in recording or reporting can result in serious omissions and untimely delays for medical care or action legally, a late entry in a chart may be interpreted on negligence. 5. ORGANIZATION The nurse or nurse manager communicates information in a logical format or order. Health team members understand information better when it is given in the order in which it is occurred. 6. ONFIDENTIALITY Nurses are legally and ethically obligated to keen information about client’s illnesses and treatments confidential