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Records and reports
This document defines records and reports in healthcare. Records provide documentation of services rendered and supply essential data for planning, evaluation, and communication between practitioners. They show health problems and factors affecting health. Records fall into two categories: those kept at health centers and those kept with patients. Reports share information orally or in writing between caregivers on services rendered and progress toward goals over a specific period. Guidelines ensure records and reports are clear, factual, securely stored, and only accessible to authorized individuals.
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Introduction to records, their purpose, types, guidelines for recording, and securing information.
Overview of reports, their purposes, types, guidelines for writing, and precautions to ensure accuracy and security.
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Records and reports
- 1. RECORDS & REPORTS PRESENTEDBY: MS. KAVITA PAL M.SC.(N) sassssss
- 2. DEFINITION: * Presenting thefacts, data, figures and other information in writing is called records, means record is the written presentation of information.
- 3. A record isa clinical, scientific , administrative and legal document relating to the nursing care given to individual, family or community.
- 4. PURPOSES: • Provides documentationof 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 recordindicates 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 bekept 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 bekept 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 secureinformation: • 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 oralor written exchanges of information shared between caregiver or workers in a number of ways.
- 14. Purposes:- 1. To showthe 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 ininterpretating 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 shouldbe 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.