records and reports ppt

7/30/2019 Records and Reports Ppt

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RECORDS AND REPORTS

Prepared by:

Mrs. Sujatha


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Relation of Record and Report

Record and report are mutually interdependent.

Report can be prepared on the basis of records.

Similarly, report can be presented as record.

Record is always in the written form while reportcan be oral as well.

Report especially oral report, can be forgotten while

record can be preserved for a long time.

Despite being literally different, record and report

are synonymous and interrelated, also they are the

essential and important component of community

health, management and nursing.


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RECORDS

Records are the information kept in the health

unit on the work of the unit, on the health

conditions in the community, on individual

patients, as well as information on

administrative, matters: staff, equipment,

supplies, etc.


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PURPOSE OF RECORDS

Records are written information in notebooks or

in folders designed for their purposes. They mayalso be kept or be computerized.

Records are the administrations memory.

Records are an important tool in controlling and

assessing work; they are kept to help thesupervisor to:

- Learn what is taking place

- Make effective decisions

- Assess progress towards goals

- Provide an insight for re planning purposes


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Types of records Records can be seen in various forms. Records

can mainly be categorized in four ways.1. Periodically:

Permanent records ( e.g cumulative records)

Temporary records (e.g casual or daily records)2. Unit based:

Individual (e.g individual health card)

Related to family (e.g family folder)

Related to community (e.g records of health

problems).

National (e.g national health programme record)


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3. Subject Based :

Economical (financial structure of family, village)

Social (records of social structure)

Political

Medical and nursing (treatment, medicine record)

4. Collection place based :

Collected at institutions (records of hospital and

health center)

Records to be kept with the individual

(immunization card, disease card)


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RECORDS RELATED TO CHN

The records in community health nursing can be

divided into two categories:

(i) Records to be kept at health centers, and

(ii) Records to be kept with the patients /individuals.


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Records at Health Centers

Family folder: Includes family, its constituent,

structure and individual card.

Mother and child health card: These can be

part of family folder. They include;

Antenatal card / Postnatal card

Immunization card

Infant card

Pre-school child cards


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Medicine distribution cards: This includes

distribution record of iron and folic acid tablets,vitamin A solution and other medicines.

Family welfare records: These includes records of

eligible couples, family Planning records, MTPrecords and other related records.

Treatment and referral records: This includes

records related to remedies of health problems,

treatment of patients, home nursing, home visiting,

and referral system.

Vital events record: These include information and

registration of birth and death records.


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General information records: This includes records of

individual, family, village and community maps, facts, pictures

and health information.

Other records and reports:

Records kept at health institution can also be categorized as

sub center records, primary or community health center

records and of district or teaching hospitals records.

- Attendance register

- Medicine stock register

- Meeting records- Monthly / yearly report

- Consumable stock register

- Movement register

- Stationary stock register

-Patient registration record

(outdoor, indoor registration

according to the category ofhealth institution)

-- Depot holder register

-- Daily diary, cumulative

record and other register


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Important types of records

Family folder card

Individual health record

FP card Antenatal card

Child health card


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RECORDS KEPT WITH PATIENTS &

MOTHERS

Though most of the records are prepared by the community

health nurse or under her guidance and are kept at the health

center, but it is more useful to keep some records with the

patients and mothers.

Generally, following records are kept with the mothers and

patients.

Health record of school going child.

Infant health card (it includes immunization card).

Maternal card

TB patient card

Individual health card


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REPORTS

Reports are the information communicated to

the other levels of the health services. They

are also an important management tool to

influence future actions.


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TYPES OF REPORTS

The types of the report are

-oral or by telephone or radio in emergency

cases (verbal)

-written in normal circumstances


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Types of reports

24 hour report

Supervisors report and Patients census report

Night and day report and

Accident report etc. are the main reports in the

field of institutional or hospital nursing, while in

the area of community health nursing

Birth and death report

Anecdotal report and the

monthly, quarterly, half yearly and annual report of

progress and evaluation of health work are also

included.


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IMPORTANCE OF RECORDS AND REPORTS

(1) Records and reports assist in assessing the health

level of the community.

(2) These provide help for health officers and

institutions in collecting data.

(3) These are useful in the assessment and evaluation

of work.

(4) Provide basis in formulating plans in the health

services. These are the symbol of future plans.

(5) These work as the tool / medium of providing

health education to individual, family and

community.

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(6) Assist in determining the need of resources

(medicines, equipments, supplies etc.)(7) These provide legal documentation for the

community health activities.

(8) These propagate the information for thecontinuity of care and nursing. These are the

means of communication between the health

workers and the community.(9) These provide information for good nursing.

(10) Without these, it is difficult to conduct

training and research work.

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(11) Record and report are essential for theevaluation, improvisation and rebuilding of

plans for the health programmes.

(12) They contribute significantly in assessing

the health problems of community.


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Records are an important tool in controlling andassessing work; they are kept to help the supervisor to:

- Learn what is taking place

- Make effective decisions- Assess progress towards goals

- Provide an insight for replanning purposes

Records are the administrations memory.

Reports are the information communicated to the other

levels of the health services. They are also an important

management tool to influence future actions.


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LEGAL IMPLICATIONS OF RECORDS&REPORTS

The legal importance of records and reports

are explained under 3 approaches:

INDIVIDUAL APPROACH

COMMUNITY APPROACH

NURSING APPROACH


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INDIVIDUAL APPROACH:

Birthdeath report, individual health card, green card

(sterilization certificate), immunization chart, maternaldescription etc. all records and reports have legal

importance. Not only in the field of health but in all fields

of life, individuals get facilities and legal protection on

the basis of records.

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COMMUNITY APPROACH:

- Health records provide confirmation, evaluation and protection ofbasic rights of citizens, related to health. Records and reports present

the legal basis through which charges can be levied against medical

administration and political system, for health problems prevalent

in the community, shortcoming in the implementation of healthprogrammes, mistakes in the evaluation, and medical &

administrative inactivity.

- Public litigation can also be filed and administration can be made

responsible for the better implementation of health programmes

under legal protection.

- Irresponsible people , organizations and enterprises can be punished

for not following the health regulations.

- Proper recording and maintenance of community health records

and reports is essential to achieve all this.

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NURSING APPROACH:

- Preserving the individual and family health

records of the patients. Adopting the right

method of filling.

-Maintaining the confidentiality and privacy of

the records of abortion, MTP, use of

contraceptives and communicable diseases.

- Records should be shown to authorized

persons only.

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- Presenting the record at the right time, in caseof consumer protection law or for any other

court work, preparing a register for it and

protecting the parent health organization/agency against contempt of court.

- For destroying obsolete records, legally

acceptable process should be used.

- Records related to medico-legal cases, dying

declaration and will etc. should be handled

carefully for giving witness, whenever needed.


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CONTENT OF RECORDS AND REPORTS

Its content (statistical information on births,

deaths, morbidity or comments on program

developments or difficulties), and its

frequency and utilization will differ fromcountry to county.

USES OF RECORDS AND REPORTS


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In assessing the quality of care and the use of

services that are delivered to clients, community

health agencies rely on the clients record.

Records should be accurately accessible and

useful. In other words, they must be truly

available when needed, and contain information

that management uses as a yardstick.


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In all health work it is important to keep

sufficient records to record is to remember.

Public health records serve to communicate

information between different health workers.

Recording is the basis for measuring diseases

and activities.

SOAPIER


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SOAPIER

SOAPIER - is an acronym used to designate therecording process, with a notation made for eachof the letters.

S - Subjective data

O - Objective data

A - Assessment

P - Planning

I - ImplementingE - Evaluation

R - Reassessment

E ti l f d ti


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Essentials of good reporting

Accurate

Legible

Complete

Short and clear

Timeliness

MAINTENANCE OF RECORDS & REPORTS


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MAINTENANCE OF RECORDS & REPORTS

Records & Reports are the essential

components of implementation and

evaluation of community health activities.

Some of the important facts related to thefilling and maintenance of records and reports

are as follows:

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1) Filling of Records: Records can be kept in many ways.

It is essential to have proper and systematic filling ofrecords.

Properly filed records save time and effort.

Filling of records depends upon the objective and method

adopted by the health agency or enterprise.

Methods of filling the records are:

(I) Alphabetically

(II) Numerically

(III)Geographically

GUIDELINES FOR RECORDING


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GUIDELINES FOR RECORDING

1. Records should be clear, appropriate and readable.

2. Records should be 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. Sentence 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 filing the records

should sign record with time and date.

Filling of report


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Filling of report

Report can mainly filed on the following basis:

1. Place: Report can be filed on the basis of group of houses,

lane or villages.

2. Time: This can be prepared as the time of completion of

work; means report can be prepared on the daily, monthly,

quarterly or annual basis.

3. Alphabet: This can be filed according to the name of thosewho started the work or the first letter of activity.

4. Number: Reports can be expressed or filed according to

numbers or in serial order, like Report No. 1,2,3,4..etc.

GUIDELINES FOR REPORTING


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GUIDELINES FOR REPORTING

1. A general method or outline of writing the report

should be prepared before actually writing report.

2. As far as possible, printed forms should be used for

writing the report.

3. It is necessary to collect all information and

material to make the report complete.

4. Style of report writing should make it easy to

understand.

5.Report should be arranged in such a manner that

essential information can be retrieved easily.

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6. Important information should be underlined

or expressed in a specific manner.

7. Presentation of report should be attractive

and the important points should be stressed.

8. Report should be comprehensive, factual and

based on supervision and actual information.

9. Wording / vocabulary of report should be

simple.

PRECAUTIONS


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PRECAUTIONS

The community health nurse should take following

precautions in the maintenance of reports andrecords:

1. These should be kept carefully at a clean space.

2. These should be protected against mice, termites and insectsetc.

3. Good filing system should be developed for the records and

reports.

4. These should be easily available on time.

5. Confidential record and report should be shown to

authorized persons only.

6. These should be kept only at the definite place.


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CONCLUSION

Record and report are mutually

interdependent. Report can be prepared on

the basis of records. Similarly the report can

be presented as record. Health record is aform of information procured from the

individual, family and community. On its basis,

doctors and nurses can provide maximumpossible health facilities to individual, family

and community.


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THANK YOU

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