RECORDSAND

REPORTS.

By:- Firoz QureshiDept. Psychiatric Nursing

DEFINITION:

* Presenting the facts, data, figures and other information in writing is called records, means record is the written presentation of information.

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

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.

• 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.

WRITING RECORDS • Does the record focus on family and community

as the object of care?• Does the record present the problem in, explicit

and dynamic terms?• Are the goals explicitly defined?• Is the action planned stated clearly?• Are family responses to the problem and the

nursing action taken clearly identifiable?

Records : Categories:

• Records to be kept at health centers and• Records to be kept with the patient or

individuals.

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

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

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.

TYPES OF RECORDS:

• CUMULATIVE OR CONTINUING RECORDS

• FAMILY RECORDS

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.

FILLING OF RECORDS:

• Alphabetically• Numerically• Geographically and • With Index cards.

REPORTS

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

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.

4. Help in interpretating the services to the public and other agencies.

5. To provide legal protection in case of litigation.

Types of reports:• VERBAL

• WRITTEN REPORT

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.

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.

Precautions:• These should be kept carefully a clean place.• These should be projected 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.