RECORDS

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RECORDS & REPORTS KIRAN RANDHAWA ARMY COLLEGE OF NURSING

RECORDS & REPORTS :

RECORDS & REPORTS RECORDS: All documented information, regardless of its characteristics, media, physical form, and the manner it is recorded or stored. Records include accounts, agreements, books, drawings, letters Records function as evidence of activities, whereas documents function as evidence of intentions. Express or presenting facts ,data, figures or other information in writing is called records means written information of information.

TYPES OF RECORDS :

TYPES OF RECORDS Can be categorized into four ways: Periodically: Permanent records (cumulative records) Temporary records (casual or daily records) Unit based records: Individual (individual health cards.) Related to family (family folders) Related to community ( community folders) National ( national health programme records)

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Subject based : Economical (financial structure of family, village ) Social ( records of social structure) Political Medical & nursing ( treatment , medicine records ) Collection place based : Collected at institutions ( records of hospitals/ health centers) Records to be kept with individual (immunization card , disease card)

RECORDS RELATED TO COMMUNITY :

RECORDS RELATED TO COMMUNITY Divided into 2 categories : Records to be kept under health centers . Records to be kept with patient . RECORDS TO BE KEPT UNDER HEALTH CENTERS: Family folders. MCH card : Antenatal Card / postnatal card Immunization card. Infant card Pre- school child card.

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Medicine distribution card include records of iron & folic acid distribution card. Family welfare records : eligible couple, MTP, family planning. Treatment & referral records. Vital event records: birth & death records. General information records: individual records, family, village, map of community. Other records: Attendance records Medicine records. Monthly / yearly records. Consumable stock register. Stationary stock register. Daily dairy, cumulative records.

RECORDS TO BE KEPT WITH PATIENT :

RECORDS TO BE KEPT WITH PATIENT Kept under supervision of community health nurse. These are : Health records of school going children. Infant health records. Maternal cards. TB patient card. Individual health cards. Birth & death records. Inpatient & outpatient records. Eligible couple records. Movement register. Medicine stock register.

REPORTS :

REPORTS Account Or Statement Describing In Detail An event, situation, or  like, usually as the result of observation, inquiry, etc. A formal or official presentation of facts . Reports means fact findings. Reports can be oral or written. Reports can be daily, monthly, quaterly , half yearly, & annual. Analytical aspect of a subject or services is presented in report.

TYPES OF RECORDS :

TYPES OF RECORDS 2 types: Verbal report Written report. In hospital important reports are : 24 hour report. Night & day report. Supervision report Patient census report Accident report. In community : Anecdotal report. Monthly, quarterly, yearly or annually reports. Evaluatory reports.

IMPORTANCE OF RECORDS & REPORTS :

IMPORTANCE OF RECORDS & REPORTS Assess health level of community. Helps in collecting data. Assessment & evaluation of work. Basis for formulate plans. Tool or medium for health education. Determine needs of resources. Legal documentation. Means of communication. Provide information of good nursing. Conduct training & research work. Assess health problems.

legal implication of records & reports :

legal implication of records & reports Explained in 3 approaches: Individual approach : birth records, death records etc all records have importance . Get facility not only from health department also from other. Community approach: Health records provide conformation & protection of rights related to health. It presents charges through which charges can be taken against medical administration & political system. It could lead to proper implementation of services.

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Nursing approach : Preserving individual records of health. Maintaining confidentiality & privacy. Should shown to authorized person. Presenting records at right time. For destroying obsolete records legally acceptable process should be used. Records of medico legal cases should be handled carefully.

MAINTENANCE OF RECORDS & REPORTS.:

MAINTENANCE OF RECORDS & REPORTS. Filling of records: Alphabetically, numerically & geographically. Guidelines: Clear, appropriate & readable Real or based on facts. Abbreviations & short forms should be of standard. Sentences should be short & clear. Signature of person filled records.

FILLING OF REPORTS :

FILLING OF REPORTS Filled by : Place: on basis of group of houses, lane or villages. Time: prepared at completion of work. Alphabetically. Guidelines: Outline should be prepared before writing actual report. Printed form. Necessary data before writing data. Style of writing should make easy to understand. Essential information should be retrieved easily. Important information should be underlined. Comprehensive & wording should be simple.

PRECAUTIONS:

PRECAUTIONS Kept carefully. Protected against termites & insects. Good filling system. Easily available on time. Kept at definite place Confidential.

Important health records:

Important health records Daily dairy : daily activities of community heath nurse. Village record: it consists: Name of village , distance from health center. Total number of families. Total population. Religious beliefs. Number of women under different age group. Number of trained dais. Number of eligible couples. Community health institutions aganwadis etc Schools, post offices, police stations, place of worship. Means of transportation & communication. Environmental condition.

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Cumulative records: Cumulative means gradual increasing in amount by one addition after another. It is continuing record procedure. Time saving , economical, review total history of individual. Evaluate progress for longer period. ( nursing student clinical record) Family folders: Condition & address of residence . Name of head of family. Religion & caste. Name of family members. Education, economic status, diet, eligible couple, environment .