RECORD AND REPORTING

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]

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 ]

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.

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.

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 record 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

CHARACTERISTICS OF GOOD RECORDING AND REPORTING:

Accuracy

Consciousness Thoroughness

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Accuracy

Consciousness

Thoroughness

Up to date

Organization

Confidentiality

Objectivity

PURPOSE OF KEEPING RECORDS:

Communication

Aids to diagnosis

Education

Documentation of continuity

Research

Legal documentation

Individual case study

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

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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TYPES OF RECORDS
1. Patients clinical record

2. Individual staff records

3. Ward records

4. Administrative records with educational value.

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 legal

b) 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

• 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.

WARD RECORDS.
Reducing or increase in beds.

Change in medical staff and non nursing

The introduction and pattern of support.

ADMINISTRATIVE RECORDS WITH EDUCATIONAL VALUE.

Treatments.

Admissions.

Equipments losses and replacements.

Personnel performance.

Other administrative records

TYPES OF RECORDS IN THE DEPARTMENT OF PUBLIC HEALTH

Cumulative or continuing records

Family records

Registers

Reports

FILLING & ARRANGING OF RECORD

Alphabetically

Numerically

Geographically

With index cards.

ALPHABETICALLY
Dictionary order

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Encyclopaedic order

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.

NUMERICALLY
Serial number

Digit filing

GEOGRAPHICALLY
Information is arranged alphabetically by geographical of place name.

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

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• Family records

RECORD KEEEPING SYSTEM

• Source records

• Problem oriented

Nursing cardex

Computerized information system

3 major categories

1) Clinical system

2) Management information system

3) Educational system

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

⚫ 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

IMPORTENCE OF RECORDS IN HOSPITAL OR HEALTH CENTERS.

• INDIVIDUAL AND FAMILY

• FOR THE DOCTOR

• FOR THE NURSE

• FOR AUTHORITIES

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: REPORTS
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]

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

: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.

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.

REPORTS IN NURSING EDUCATION

• Factual data related to the students, staff, clinical facilities, physical facilities, administration
and the curriculum

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• Development made in the school programme since the last report.

Proposal and plans for future development.

• Problems encountered

Recommendations

TYPES OF REPORTS
Important points are emphasized

• In case of oral reports they are clearly expressed and presented in an interesting manner.

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

1. 24 hours reports

2. Census report

3. Anecdotal report

4. Birth and death report

5. Incidental report

CLASIFICATION OF REPORTS BASED ON TYPES

Oral reports

• Written reports

REPORTS USED IN HOSPITAL SETTING:

• CHANGE-OF-SHIFT REPORTS

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• TRANSFER REPORTS

• INCIDENT REPORTS

• LEGAL REPORTS

ADVANTAGES AND DISADVANTAGES OF REPORTS

ADVANTAGES
Monitoring operations

Controlling

Guide decision

Employee motivation

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

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

COMMON PROBLEMS THAT OCCUR DURING REPORT WRITING.

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CONTENT AND ORGANIZATION
• Problem - No section headings

• Problem - missing items related to the format

• Problem - lack of numbering

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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