2. INTRODUCTION
All documents information , regardless its
characteristics, media, physical form and the manner
it is recorded or stored.
Records function as evidence of activities.
Express or presenting facts, data, figures or other
information in writing is called records means written
inf. Of information.
3. RECORDS
.
Health records refers to the forms
on which information about an
individual or family is recorded
4. REPORTS
these are 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 .
5. TYPES OF RECORDS
1.) PERIODICAL:
A.) Permanent records (cumulative)
B.) Temporary records(casual/daily records)
6. CONT….
2.) UNIT BASED RECORDS:
a.) individual(individual health cards)
b.) related to family(family folders)
c.) related to community(community folders)
d.) National(national health programms records)
7. Cont….
3.) SUBJECT BASED:
a.) economical(financial structure of family, village
b.) social(records of social structure
c.)Political
d.)Medical and nursing (treatment and medicine
recods))
8. Cont….
4.) COLLECTION PLACE BASED:
a.) Collected at institutions(records of hospitals/ ealth
centers
b) Records to be kept with the individual(immunization
cards, disease cards)
9. Records related to community
2 categories:
A.) Records to be kept under health centers
B.)Records to be kept with the patient
10. Records to be kept under health centers
1) family folders
MCH cards
Antenatal card/ postnatal cards
Infant card
Pre-school child card
Medicine distribution card include records of iron
and folic acid distribution cards
Family welfare records: eligible couple, mtp, family
planning.
11. Cont…….
Treatment and referral records
Vital event records: birth and death records
General information records; individual records,
family, village, map of community
Other records:
- antenatal records
- Medicine records
- Monthly/ yearly records
- Consumable stock register
13. To be kept with the Patient
Kept under supervision of community health nurse:
These are:
- health record of school going children
- infant health card
- maternal card
- tb patient card
- individual health card
- Birth and death record
- Inpatient and outpatient record
15. IMPORTANT HEALTH RECORDS
1.) Daily diary: daily activities of community health
nurse
2.) Village record: it consist of
Name of village,
distance from health center
Total no of families
Total population
Religious beliefs
No. of women under different age group
16. Cont….
No of trained dais
No of eligible couples
Community health institutions anganwari etc
Schools, post offices, police stations, place of
worship
Means of transportation and communication
Environment conditions
17. Cummulative records
Cumulative means gradual increasing in amount by
one adding after another
It is continuing record procedure
Time saving, economical, review total history of
individual
Evaluate progress for longer peroid (nursing
students clinical record)
18. Family folder
Condition and address of residence
Name of head of family
Religion and cast
Name of family member
Education, occupation, economic status, diet,
eligible couple, environment.
19. REPORTS
Account or statement describing in detail an event,
situation or like usually as the result of observation,
inquiry etc.
20. Cont…..
A formal or official presentation of facts
Reports means fact findings
Reports can be oral or written.
Can be daily, monthly, quarterly, half yearly and
annual.
Analytical aspect of a subject or services is
presented in a report.
21. TYPES OF REPORTS
2 TYPES:
1.) Verbal report
2.) Written report
In hospital important reports are;
24hrs reports
Night and day report
22. Cont….
Supervision report
Patient census report
Accident report
IN COMMUNITY:
Anecdotal reports
Monthly, quaterly, yearly or annually reports
Evaluatory report
23. IMPORTANCE OF RECORDS AND
REPORTS;
Assess health level of community.
Helps in collecting data.
Assessment and evaluation of work.
Basis for formulating plans
Tool or medium for health education.
Determine needs of resources.
Legal documentation
Means of communication
Provide information of good nursing
Conduct training and research work
Assess health problems.
24. MAINTANENCE OF RECORDS AND
REPORTS
Filling of records: Alphabetically, numerically and
geographically.
GUIDELINES:
Clear, appropriate and readable.
Real or based on facts.
Abbribations and short forms should be of standard.
Sentences should be short and clear.
Signature of person filled records.
25. 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
