Records&Reports

8/10/2019 Records&Reports

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RECORD REPORT

(RECORDING REPORTING)

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PURPOSES OF RECORDS

1.Supply data that are essential for programmeplanning and evaluation.

2. To provide the practitioner with data requiredfor the application of professional services for

the improvement of familys health.

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3. Records are tools of communication

between health workers, the family, and

other development personnel.4. Effective health records shows the health

problem in the family and other factors that

affect health.5. A record indicates plans for future.

6. It provides baseline data to estimate the

long-term changes related to services.

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PRINCIPLES OF RECORD WRITING

1. Nurses should develop their ownmethod of expression and form in

record writing.

2.Records should be written clearly &

appropriately.

3.Records should contain facts based onobservation, conversation and action.

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4. Select relevant facts and the recording

should be neat, complete and uniform

5.Records should be written immediately

after an interview.6. Records are confidential documents.

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Administrative purpose of clinical

records

Legal documents: poisoning, assault, rape,LAMA, burn etc.

Research or statistics: rates

Audit and nursing audit Quality of care

Continuity of care

Informative purposes: census Teaching purpose of students

Diagnostic purposes: test reports


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TYPES OF RECORDS

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. (e.g.)

childs record should provide space for newborn,

infant and preschool data. The system of using one record for home and clinic

services in which home visits are recorded in blue andclinic visit in red ink helps coordinate the services and

saves the time.

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2. Family records

The basic unit of service is the family. All

records, which relate to members of family,

should be placed in a single family folder. This

gives the picture of the total services and helps

to give effective, economic service to the familyas a whole.

Separate record forms may be needed for

different types of service such as TB, maternity

etc. all such individual records which relate tomembers of one family should be placed in a

single family folder.

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Importance of Records in Hospital

1. For the individual and family:

- Serve the history of the client

- Assist in continuity of care- Evidence to support if legal issues arise

- Assess health needs, research and

teaching.

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2. For the Doctor:

- 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

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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.

- Indicate plan for future

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4. For authorities:- Statistical information

- Administrative control

- Future reference

- Evaluation of care in terms of quality, quantity

and adequacy.

- Help supervisor to evaluate service

- Guide staff and students

- Legal evidence of service render by eachemployee

- Provide justification of expenditure of funds.

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Purposes of records

1.COMMUNICATION

2.FINANCIAL BILLING

3.EDUCATION4.ASSESSMENT

5.RESEARCH

6.AUDITING AND MONITORING7.LEGAL ASPECT

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Records in the nursing office & Unit

- Administrative records: Organogram, jobdescription, procedure manual

- Personnel records: personal files, records

- Patient related records: patients records sendto Medical director

- Leave record, duty roster, meeting minutes,

budget etc

- Miscellaneous: circular, round book, formats etc

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FILLING OF RECORDS

Different systems may be adopteddepending on the purposes of the records

and on the merits of a system.

The records could be arranged: Alphabetically

Numerically

Geographically and With index cards

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REGISTERS

It provides indication of the total volume of

service and type of cases seen. Clerical

assistance may be needed for this.Registers can be of varied types such as:

immunization register,

clinic attendance register,

family planning register,

birth register and

death register.

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GUIDELINES FOR QUALITYDOCUMENTATION AND

REPORTING.a) Factual basis

b) accuracy

c) completenessd) accuracy

e) organization

f) confidentiality

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Keep under safe custody of nurses.

No individual sheet should be separated.

Not accessible to patients and visitors. Strangers is not permitted to read records.

Records are not handed over to the legal

advisors without written permission of theadministration.

Handed carefully, not destroyed.

NURSES RESPONSIBILITY FOR

RECORD KEEPING AND REPORTING

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cont..

Identified with bio-data of the patientssuch as name , age, admission number,

diagnosis, etc. (Legal Issues?)

Never sent outside of the hospital withoutthe written administrative permission.

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SYSTEM OF MEDICAL RECORD

In the modern age, Medical Record has itsutility and usefulness and is a very broad

based indicator of patients care.

The policy is to keep indoor patient Recordsfor 10 years

The OPD registers for 5 years

The record which is register for legalpurposes in Maintained for 10 years or tillfinal decision at the court of Law.

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FUNCTIONS OF MEDICAL RECORD DEPARTMENT

1. Daily receipt of case sheets pertaining todischarge and expired patients from variouswards, there checking and assembly.

2. Daily compilation of Hospital census report.

3. Maintains & retrieval of records for patientcare and research study.

4. Completion and Procession of Hospitalstatistics and preparation on differentperiodical reports on morbidity andmortality.


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5. Online registration of vital events ofBirth & Death.

6. Issuing Birth & Death certificated upto one year.

7. Dealing with Medico Legal recordsand attending the courts onsummary.

8. Arrangement & Supervision ofenquiry and admission office.

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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. These are based on records and registers and so

it is relevant for the nurses to maintain the records

regarding their daily case load, service load and

activities.

Thus the data can be obtained continuously and

for a long period.

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NURSING REPORTS

oReports are information about a patient

either written or oral.

-sr. Nancy

oA report is a summary of activities or

observations seen, performed or heard.

-Potter and Perry

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PURPOSES OF WRITING REPORTS

To show the kind and quantity of servicerendered over to a specific period.

To show the progress in reaching goals.

As an aid in studying health conditions.

As an aid in planning.

To interpret the services to the public and to

other interested agencies.

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CLASSIFICATIONOF REPORTS

ORAL REPORTS

WRITTEN PERSON

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1 Change of shift report

2 Telephone reports

3 Telephone orders

4 Transfer reports

5 Incident reports

6 Legal reports

TYPE OF REPORTS

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Can be made promptly

Clear, concise and complete

All pertinent, identifying data included

Mention all people concerned, situation

and signature of person making report

Easily understoodImportant points are emphasized

CRITERIA OF GOOD REPORT

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Key Messages

Written policies and procedures are

the backbone of the quality system

Complete quality assurance recordsmake quality management possible

Keeping records facilitates meeting

program reporting requirements


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Records and reports revels theessential aspects of service in

such logical order so that the

new staff may be able tomaintain continuity of service

to individuals, families andcommunities.

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Documentation Details

A nurse can skip a question on an

assessment if he/she is unable to assess

the question due to patient condition or if

the question is not applicable for thepatient at that time

Any retrospective documentation can be

entered up to 3 days following patientdischarge. ?


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Documentation Details

Changes to documentation may only be

made by the person who recorded the

documentation

Partially documented entries,

documentation editing, and undoing

documentation can be completed by

clicking in the History column for theappropriate intervention


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SYSTEM OF MEDICAL RECORD

DEFINITION

Medical Record of the patient stores the

knowledge concerning the patient and his care. It

contains sufficient data written in sequence ofoccurrence of events to justify the diagnosis,

treatment and outcome.

In the modern age, Medical Record has its utility

and usefulness and is a very broad based

indicator of patients care.


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Flow of Medical Record :-The flow chart of inpatient Medical Record is as

under :-

Central Admission

Office

Wards

Medical Record Department

1. Assembling

2. ADMN. &

Discharge

analysis

3. Storage Area

Afetr completion of

Records

Hospital statistics prepared

Monthly/Yearly

Medical Record is filled for perusal of

Patients/claims/research purposes.


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FILING OF MEDICAL RECORDS

The inpatients Medical Record is filed by the

serial numbers assigned at central AdmittingOffice.

The Record is bound in bundles 100 eachand are kept year wise according to the serial

number.RETENTION OF MEDICAL RECORD

The policy is to keep indoor patient Recordsfor 10 years

The OPD registers for 5 years The record which is register for legal

purposes in Maintained for 10 years or tillfinal decision at the court of Law.


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Thank You

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Records&Reports