RECORDS AND

REPORTSPRESENTED BY

ANU JAMES. MSc (N)

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RECORDS

DEFINITION:

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.

[ S.L.Geol, 2001 ]

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DEFINITION (CONTND…….)

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

[ Sr. Mary lucita ]

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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.

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Principles of maintaining records (contnd…)

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.

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Principles of maintaining records (contnd…)

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

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CHARACTERISTICS OF GOOD RECORDING AND REPORTING:

Accuracy Consciousness Thoroughness Up to date Organization Confidentiality Objectivity

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• Communication

• Aids to diagnosis

• Education

• Documentation of continuity

• Research

• Legal documentation

• Individual case study

PURPOSE OF KEEPING RECORDS:

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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

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USES OF RECORDS (contnd….)

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

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1. Patients clinical record2. Individual staff records3. Ward records4. Administrative records with educational

value.

TYPES OF RECORDS

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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.

a) Scientific and legalb) Evidence to the patient the his /her case is

intelligently managed.c) Avoids duplication of work.d) Information for medical and legal nursing research.e) Aids in the promotion of health and care.f) Legal protection to the hospital doctor and the

nurse

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PATIENTS CLINICAL RECORDS (contnd..)

• 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.

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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

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WARD RECORDS.

• Reducting or increase in beds.• Change in medical staff and non nursing

personnel for the ward.• The introduction and pattern of support.

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ADMINISTRATIVE RECORDS WITH EDUCATIONAL VALUE.

• Treatments.• Admissions.• Equipments losses and replacements.• Personnel performance.• Other administrative records

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TYPES OF RECORDS IN THE DEPARTMENT OF PUBLIC HEALTH

• Cumulative or continuing records• Family records• Registers• Reports

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FILLING & ARRANGING OF RECORD

• Alphabetically• Numerically• Geographically• With index cards.

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ALPHABETICALLY

• Dictionary order • Encyclopaedic order

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Advantages and disadvantages of alphabetically arrangement system

Advantages • Most people are familiar • Staff should be able to learn

and become comfortable with the system in a timely manner

• The need to shift the records after purging records is reduced

• Cross reference may be avoided

Disadvantages • system does not work well

with very large filing systems• Color coding is more difficult

since you need to have 26 colors or combination of colors to designate all the letters of the alphabet

• Confidentiality is an issue • Some of the rules of alpha

filing can be very confusing.

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NUMERICALLY

• Serial number • Digit filing

GEOGRAPHICALLY Information is arranged alphabetically

by geographical of place name.

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WITH INDEX CARDS

• An index card consists of heavy paper cut to a standard size, used for recording and storing small amounts of discrete data. It was invented by Carl Linnaeus, around 1760.

Eg:- forms, case records and registers. Diaries- diary of M & F Return – monthly report of HW (M& F)In addition each organization should maintain• Cumulative records• Family records

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RECORD KEEEPING SYSTEM

• Source records• Problem oriented• Nursing cardex• Computerized information system

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Computerized information system3 major categories

1) Clinical system2) Management information system3) Educational system

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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

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GUIDELINES FOR DOCUMENTATION AND RECORD KEEPING (contnd..)

• 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

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IMPORTENCE OF RECORDS IN HOSPITAL OR HEALTH CENTERS.

• INDIVIDUAL AND FAMILY• FOR THE DOCTOR• FOR THE NURSE• FOR AUTHORITIES

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REPORTS

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DEFINITION 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

[ Basvanthappa bt.2009 ]

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DEFINITION (contnd..)

Reports are oral or written exchanges of information shared between care givers of workers in a number of ways. A report summarises the service of the personnel and of the agency

[ Jean b. 2002 ]

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PURPOSES

• 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.

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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.

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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

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TYPES OF REPORTS

1. 24 hours reports2. Census report3. Anecdotal report4. Birth and death report5. Incidental report

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CLASIFICATION OF REPORTS BASED ON TYPES

• Oral reports• Written reports

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REPORTS USED IN HOSPITAL SETTING:-

• CHANGE – OF – SHIFT REPORTS• TRANSFER REPORTS• INCIDENT REPORTS• LEGAL REPORTS

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ADVANTAGES AND DISADVANTAGES OF REPORTS

ADVANTAGES

• Monitoring operations• Controlling• Guide decision• Employee motivation• Performance evaluation

DISADVANTAGES • 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

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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

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COMMON PROBLEMS THAT OCCUR DURING REPORT WRITING.

CONTENT AND ORGANIZATION

• Problem - No section headings• Problem - missing items related to the

format• Problem - lack of numbering

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Common problems that occur during report writing.(Contnd..)

GRAMMAR, VOCABULARY, SENTENCE AND TONE.OTHER PROBLEMS

• Incomplete sentences • Confusing and unclear sentences.• Miscommunication• Too general• Confidentiality.• Missing information and facts.• Wordiness.

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