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Record and Report

  5. DEFINITION A record is a permanent written communication, that documents informations which is relevant to a client’s health care management.
  6. PRINCIPLES Be Written clearly Understandable. Be completed and should give accurate information. Be filed serially numbered and properly arranged. True facts based on observation,conversation and action. Continuity should be maintained. Always be printed.
  7. Be written immediately after service. Be kept confidential. Not be kept blank. CONT..
  8. TYPES OF RECORDS A. CLINICAL RECORDS -Handwritten clinical notes -Electronic health records -E-mails -Official letters from top level health management team -Laboratory reports and X-rays -Anecdotes -Photographs -Audio visual media (audio and video tapes, digital recordings,CDs,DVDs) -Tape recordings of telephone conversation -Text messages B. MANUAL RECORDS -Newborn health record -Preschool health record -Immunisation record -Antenatal health record -Postnatal health record -Morbidity record
  9. REGISTERS MAINTAINED BY STAFF NURSE/ANM -Nurse report book -TT injection register -Antenatal clinic register -Postnatal clinic register -IUD registers -Under 5 clinics registers -Laundry register REGISTERS MAINTAINED BY VILLAGE HEALTH NURSE -Family and eligible couple register -Mother care register -Child care registers -Minor ailments treatment registers -Referral register -Drug stock register -NRHM related activites register
  10. REGISTERS MAINTAINED BY MALE HEALTH WORKER -Family register -Disease surveillance register -Program register -School health register -Inspection register -Drugs,equipement registers -Birth and death issue register -Tobacco control activity related registers -Register of vital statistics -Weekly review register -Report on inspection and case sheets SCHOOL HEALTH PROGRAM -Student health appraisal register -Referral slip and follow up register -Home visit register -Monthly activity report
  12. A. FOR NURSES ● The record provides the services done- what is being done, what is to be done and the goals to be achieved toward health. ● Record provides basis for planning the interventions. ● Record prevents duplication of services and helps follow-up services effectively. ● Record helps the nurse to organise her work and saves time. ● Record serves as a guide to professional growth.
  13. B. FOR DOCTORS ● The record serves as a guide for diagnosis and treatment, follow-up, and evaluation of services. ● Records indicate progress of the patient and continuity of care. ● Records protect the doctor in case of legal issues. ● Records used for a doctor in teaching, research and medical practice.
  14. C. FOR HEALTH AGENCY ● The record helps the administrator in assessing the performance of their own institutions and the needs of the society. ● The record helps in making studies for research, for legislature action and for planning budget. ● Record provides a justification for expenditure of funds. ● Record helps in the guidance of staff, students, employees and other categories. ● Planned records are utilised as an evaluation tool during conferences and meetings. ● Records provide quality and quantity of their services.
  15. D. FOR A HEALTH WORKER AT VILLAGE LEVEL ● The record will help the nurse to know about the details of pregnant women making use of antenatal services such as registration, history, TT, immunisation, feeding, high- risk conditions, antenatal examination and the future plan for delivery and condition of fetus, etc. (MCH Registers). ● The mother care register provides the details of delivery conducted, by whom, sex of the baby, place of delivery, birth weight, etc. ● The birth and death register provides the number of births and deaths in a day, month and year, causes of death. ● Referral register provides the details of the referred cases. ● Child care register provides information about immunisation, date of birth, age, sex, place of birth and birth weight, etc. ● Growth chart provides weight taken, grading of malnutrition, height and sickness, etc.
  16. E. FOR THE FAMILY AND INDIVIDUAL The records help the individual and family to become aware of their health needs.
  17. ROLE OF COMMUNITY HEALTH NURSE ● Be written clearly, legibly in non-erased material and must be dated with time and signature. ● The signatory's name designation/role must be written in the record. ● Records must be factual, complete, consistent, accurate and consecutive. ● Avoid complicated jargon.
  18. ● Record only relevant and useful information. ● Do not overwrite or use erasers or fluid to cancel errors. ● It should be visible, readable when photocopied or scanned. ● Keep records securely and confidentially. ● Store under lock and key. ● Care must be taken to secure confidentiality of electronic records; specifically when it is shared or transferred.
  21. DEFINITION Report is oral or written exchange of information shared between health team.
  22. PURPOSE To show the amount of service rendered over a specified period. It acts as an aid in studying health conditions. It acts as an aid in planning. Good reports are time saver. Prevent duplication of work.. Provide a sense of security and confidence to the nurse in doing her work.
  24. TYPES OF REPORTS 24 HOUR REPORT ➢ Provide only essential background information about client (name, age sex, diagnosis and medical history) ➢ Identify clients' nursing diagnosis or health care problems and other related causes. ➢ Describe objective measurements or observations about clients' condition and response to health problems. ➢ Share significant information about family members, as it relates to clients' problems. ➢ Continuously review ongoing discharge plan. TRANSFER REPORT A transfer reports involve communication of information about clients from the nurse on sending unit to the nurse on the receiving unit. Nurse should include the following information. ➢ Client's name, age, primary doctor, and medical diagnosis. ➢ Summary of medical progress up to the time of transfer. ➢ Current nursing diagnosis or problems and care plan. ➢ Any critical assessment or interventions to be completed shortly.
  25. INCIDENT REPORTS ➢ The nurse who witnessed the incident or who found the client at the time of incident should file the report. ➢ The nurse describes in concise what happened specifically objective terms, etc. ➢ Any measures taken by the nurse, other nurses, or doctors at the time of the incident are reported. ➢ The report is submitted as soon as possible. ➢ The nurse should never make photocopy of the incident report.
  26. . CENSUS REPORT This is a report compiled daily for the number of patients. Very often it is done at midnight and the norms are collected by the night supervisor. The report will show the total number of patients,the number of admissions, discharges, transfers, births and deaths. The nurses should remember that a single mistake in the census figures made by one of the nurses make the census report of the entire institution incorrect.
  27. BIRTH AND DEATH REPORTS The nurses are responsible for sending the birth and death reports to governmental authorities for registration within the specified time.
  28. An anecdote is brief account of some incident. Incident reports and reports on accidents, mistakes and complaints are legal in nature. A written record concerning some observation about a person or about her work is called an anecdote note.
  29. LEGAL IMPLICATION IN MAINTAINING RECORDS ➔Prescription of drugs by the physicians for treatment and care of the patient. ➔Registration of births, deaths and stillbirths are the important vital events. ➔Medicines should be administered as per the order of physician and also under supervision. ➔Checking the labels of drug and it should also be charted accurately before administration.
  30. ➔Informed consent is essential before surgery or investigation of the patients. ➔Identification of babies in labor ward by labels. ➔Identification of dead bodies in mortuary. ➔Reporting of accidents, incompetent behaviours. errors. ➔Confidentiality in record working and maintenance.
  31. Maintaining good quality records and reports has both immediate and long- term benefits for staff. In the long term it protects individuals and teams from accusations.
  32. ASSIGNMENT Why proper records and reports are important in health field?
  33. Insert your subtitle here Thank you