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1. Presented by:
Kalyani R. Saudagar

2.  Records
 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, circular, reports, contracts, invoices, vouchers,
minutes of meetings, books of account etc.
(S.L.Geol,2001)
• It is a written communication that permanently documents
information relevant to a clients health care management. It
is a continuing account of the clients health care needs.
( Sr. Mary lucita )

3. Importance of Records
 For the individual and family:
• Serve the history of client
• Assist in continuity of care
• Evidence to support if legal issues arise
• Assess health needs, research and teaching
 For the doctor:
• Serve the guide for diagnosis, treatment, follow up and evaluation
• Indicate progress and continuity of care
• Self evaluation of medical practice
• Protect doctor in legal issues
• Used for teaching and research
 For the nurses:
• Document nursing service rendered
• Shows progress
• Guide for professional growth
• Indicate plan for future
• Judge the quality and quantity of work done
• Planning and evaluation of service for future improvement
• Communication tool between nurse and other staff involved in the care

4. For authorities :
• Statistical information
• Administrative control
• Future reference
• Evaluation of care in terms of quality, quantity
and adequacy
• Help supervisor to evaluate service
• Guide staff and students
• Legal evidence of service render by each
employee
• Provide justification of expenditure of funds

5. 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 program
 Adequate, safe, fireproof, storage arrangements

6. CLASSIFICATION OF RECORDS
Active Record – a record that is regularly
referenced or required for current use
Inactive Record – a record that is still
needed by an organization but not for
current operations
Electronic Record – a record recorded or
formatted only a computer can process

7. CHARACTERISTIC OF GOOD
RECORDING AND REPORTING
ACCURACY
CONSCIOUSNESS
THOROUGHNESS
UP TO DATE
ORGANIZATION
CONFIDENCIALITY
OBJECTIVITY

8. PURPOSE OF KEEPING
RECORDS:
 Communication
 Aids to diagnosis
 Education documentation of continuity
 Research
 Legal documentation
 Individual case study

9. RECORDS IN THE NURSING
OFFICE AND UNIT
• Administrative records: Organogram, job
description, procedure manual
• Personnel records: personal files, records
• Patient related records: patients records
send to medical director
• Leave record, duty record, meeting
minutes, budget etc
• Miscellaneous: circular ,round book,
formats etc

10. Administrative purpose of
clinical records
• Legal documents: poisoning, assault, rape,
LAMA, burn etc
• Research or statistics: rates
• Audit and nursing audit
• Quality of care
• Continuity of care
• Informative purposes: man and female
census
• Teaching purpose of students
• Diagnostic purposes: test reports

11. 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 nurse to evaluate the care and the
teaching
 Organization of work
 Serves as guide for diagnosis treatment and
evaluation of services
 Indicate progress
 Used in research
 The health assets and needs of the village area

12. TYPES OF RECORDS
Patients clinical
record
Individual staff
records
Ward records
Administrative
records with
educational
value

13. 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

14. 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 record
a) Reducting or increase in beds
b) Change in medical staff and non nursing
personnel for the ward
c) The introduction and pattern of support

15. Administrative records with
educational value
a) Treatments
b) Admission
c) Equipments losses and replacements
d) Personnel performance
e) Other administrative records

16. Types of records in the
department of public health
I. Cumulative or continuing records
II. Family records
III. Registers
IV. reports

17. Filling and arranging of records
 Alphabetically
 Numerically
 Geographically
 With index cards
Alphabetically
• Dictionary order
• Encyclopedic order

18. Advantages and disadvantages of
alphabetically arrangement system
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 filling 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
filling can be very confusing

19. 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
• family records

20. Record keeping system
• Source records
• Problem oriented
• Nursing cardex
• Computerised information system

21. 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 son 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 alteration or
additions are dated, timed and signed, so that the
original entry is still clear
• Be accurately dated, timed and signed, with the
signature, irrelevant speculation and offensive
subjective statements
• Be readable on any photocopies

22. Importance of records in
hospital or health centers
• Individual and Family
• For the Doctors
• For the Nurse
• For Authorities

23. Nurses responsibility for record
keeping
o Keep under safe custody of nurses
o No individual sheet should be separated
o Not accessible to patients and visitors
o Strangers is not permitted to read records
o Records are not handed over to the legal
advisors without written permission of the
administrative
o Handed carefully. Not destroyed
o Identified with bio-date of the patients such
as name, age, admission number, diagnosis,
etc.(legal issues?)
o Never sent outside of the hospital without the
written administrative permission

24. PRECAUTIONS:
1) Kept carefully
2) Protected against termites and insects
3) Good filling system
4) Easily available on time
5) Kept at definite place
6) confidential

25. THANK
YOU