This lesson will help the nursing students to learn and know the nursing records and reports and responsibility of the nurse in maintaining nursing records and reports in various health settings.

2. Nursing Records and
reports
PRESENTED BY-
SAURABH SINGH TOMAR
ASSIT.PROFESSOR
(COMMUNITY HEALTH NURSING)
E-MAIL-saurabh.singh406@gmail.com

3. Records

4. DEFINITION
1. 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.
According to S.L.Geol, 2001
2. 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
According Sr. Mary lucita ]

5. PRINCIPLES OF MAINTAINING
RECORDS
1. Specific purpose which should be clearly understood
2. Items on forms and in registers should be conveniently grouped so as to make
their completion as easy as possible.
3. The wording should be easily understood, and where doubt is likely to arise,
instructions to facilitate interpretation should be included.
4. Records should permit some freedom of expression.
5. Records which are required by the teaching staff should be easily accessible
to them.
6. 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.

6. PRINCIPLES OF MAINTAINING
RECORDS
7. Provision for periodic review of all records to ensure that they keep
pace with the changing needs of the programme.
8. Adequate supply of stationery to permit records to be maintained on
the proper forms and in the proper registers at all times.
9. Sufficient number of filing cabinets and appropriate equipments to
operate a filing system which is simple and safe and requires the
minimum possible time.
10. Adequate, safe, fireproof storage arrangements

7. CHARACTERISTICS OF RECORDS
ACCURACY
CONSCIOUSNESS
THOROUGHNESS
UP TO DATEORGANIZATION
CONFIDENTIALITY
OBJECTIVITY

8. PURPOSE OF KEEPING
RECORDS
1. Communication
2. Aids to diagnosis
3. Education
4. Documentation of continuity
5. Research
6. Legal documentation
7. Individual case study

9. USES OF RECORDS
1. Show the health conditions as it is and as the patient and family
accepts it.
2. goals towards which means are to be directed.
3. prevents duplication of services and helps follow up services
effectively.
4. Helps the nurses to evaluate the care and the teaching
5. Organization of work
6. Serves as a guide for diagnosis treatment and evaluation of
services
7. indicate progress
8. Used in research
9. The health assets and needs of the village area

10. TYPES OF RECORDS
1) PATIENTS CLINICAL RECORD
2) INDIVIDUAL STAFF RECORDS
3) WARD RECORDS
4) ADMINISTRATIVE RECORDS WITH
EDUCATIONAL VALUE.

11. 1) 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

12. PATIENTS CLINICAL RECORDS
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.

13. 2. 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

14. 3. WARD RECORDS
Reducing or increase in beds.
Change in medical staff and non nursing
personnel for the ward.
The introduction and pattern of support.

15. 4. ADMINISTRATIVE RECORDS WITH
EDUCATIONAL VALUE
Treatments.
Admissions.
Equipments losses and replacements
 Personnel performance.
 Other administrative records

16. TYPES OF RECORDS IN THE
DEPARTMENT OF PUBLIC
HEALTH
1. CUMULATIVE OR CONTINUING RECORDS
2. FAMILY RECORDS
3. REGISTERS
4. REPORTS

17. 1. CUMULATIVE OR CONTINUING
RECORDS
• This is found to be time saving, economical and also it is
helpful to review the total history of an individual and
evaluate the progress of a long period.
• A cumulative record is a systematic account of information
about a student. It is an evaluation tool which presents a
comprehensive record of the achievement or otherwise of
each student in different aspect-physical academic, moral,
social and health.

18. 2. FAMILY RECORDS
 All records, which relate to members of family, should be
placed in a single family folder. Gives the picture of the
total services and helps to give effective, economic service
to the family as a whole.
 Separate record forms may be needed for different types
of service such as TB, maternity etc. all such individual
records which relate to members of one family should be
placed in a single family folder.

19. GUIDELINES FOR DOCUMENTATION
AND RECORD KEEPING
The Nursing and Midwifery Council (NMC 2002) has said that
patient and client records should:
1. be based on fact, correct and consistent
2. be written as soon as possible after an event has happened
3. be written clearly and in such a way that the text cannot be
erased
4. be written in such a way that any alterations or additions are
dated, timed and signed, so that the original entry is still clear
5. be accurately dated, timed and signed, with the signature
printed alongside the first entry
6. not include abbreviations, jargon meaningless phrases,
irrelevant speculation and offensive subjective statements
7. be readable on any photocopies

20. IMPORTENCE OF RECORDS IN
HOSPITAL OR HEALTH CENTERS.
1. INDIVIDUAL AND FAMILY
2. FOR THE DOCTOR
3. FOR THE NURSE
4. FOR AUTHORITIES

21. VALUE AND USES OF RECORDS IN
HOSPITAL AND HEALTH CENTRE
1.FOR THE INDIVIDUAL AND FAMILY
I. Records serve to document the history of the
client.
II. Records assist in the continuity of care.
III. Records serve as evidence to support or to
manage or face the legal questions that arise.
IV. Records serve to recognize the health needs and
can be used as a research and teaching tool.

22. 2. FOR THE DOCTOR
I. Serves as guide for diagnosis, treatment, follow
up and evaluation of services.
II. Indicate progress and continuity of care.
III. Help self evaluation of medical practice.
IV. Protect the doctor in case of legal issues.
Records may be used for teaching and
research.

23. 3. FOR THE NURSE
I. Provide with documentation of services
rendered, i.e. shows health condition of the
client.
II. Provide data essential for planning and evaluation
of services for further improvement.
III. Serve as a guide for professional growth.
IV. Enable to judge the quality and quantity of work
done.
V. Serve as communication tool between staff and
other members involved in care.
VI. Indicate plans for the future. For Authorities
VII. Provide the management with stati

24. 4. FOR AUTHORITIES
I. Provide the management with statistical
information necessary for decision in regard to
utilization of resources, planning for
administrative control and future references.
II. Help the supervisor evaluate the services
rendered, teaching done and a person’s action
and reactions

25. RECORD MAINTENANCE IN
COMMUNITY SETTING
1.FORMS, CASE CARDS AND REGISTERS.
i. Family record
ii. Eligible couple and child register
iii. Sterilization and IUD register
iv. MCH Card/ register
v. Child Card/ register
vi. Birth and death register
vii. Sub centers/PHC/clinic register
viii.Stock & Issue register
ix. Reports of blood test of Malaria and Filaria
x. Malaria parasite positive case register and
others

26. 2.DIARIES
i. Diary of (M and F)
ii. Diary of HA (M and F)
3.RETURN-
i. Monthly report of HW ( M and F)
ii. Complication report of HW (M and F)
PHC Monthly report In addition, each organization should
maintain:
i. Cumulative records
ii. Family records

27. RECORD MAINTENANCE IN
HOSPITAL
i. The patient’s clinical record
ii. Records of nurses’ observations – Nurses’
Notes
iii. Records of orders carried out
iv. Records of treatment
v. Records of admission and discharge
vi. Records of equipment loss and replacement (
inventory)
vii. Records of personnel performance.

28. Nursing
Reports

29. DEFINITION
1. 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
According to BASVANTHAPPA BT.2009
2. Reports are oral or written exchanges of information shared
between care givers of workers in a number of ways. A report
summarizes the service of the personnel and of the agency
According to JEAN B. 2002

30. PURPOSES
1. Report is an essential tool to communication
2. To show the kind and amount of services
rendered over a specific period.
3. To illustrate progress in teaching goals.
4. As an aid in studying health condition.
5. As an aid in planning.
6. To interpret the services to the public and to
the other interested agencies.

31. CRITERIA FOR A GOOD
REPORT
1. Made promptly.
2. Clear, concise, and complete.
3. 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.
4. It is clearly stated and well organized
5. Important points are emphasized.
6. In case of oral reports they are clearly
expressed and presented in an interesting
manner.

32. REPORTS IN NURSING
EDUCATION
1. Factual data related to the students, staff,
clinical facilities, physical facilities,
administrationand the curriculum
2. Development made in the school programme
since the last report.
3. Proposal and plans for future development.
4. Problems encountered
5. Recommendations

33. TYPES OF REPORTS
1. 24 hours reports
2. Census report
3. Anecdotal report
4. Birth and death report
5. Incidental report

34. CLASIFICATION OF REPORTS
BASED ON TYPES
1. ORAL REPORTS
2. WRITTEN REPORTS
1. ORAL REPORTS : Oral reports are given when the
information is for immediate use and not for permanency.
 E.g. it is made by the nurse who is assigned to patient care, to
another nurse who is planning to relieve her.
2. WRITTEN REPORTS : Reports are to be written when the
information to be used by several personnel, which is more or
less of permanent value,
 E.g. day and night reports, census, interdepartmental reports,
needed according to situation, events and conditions.

35. REPORTS USED IN HOSPITAL
SETTING
1. CHANGE – OF – SHIFT REPORTS
2. TRANSFER REPORTS
3. INCIDENT REPORTS
4. LEGAL REPORTS

36. ADVANTAGES AND
DISADVANTAGES OF REPORTS
 Monitoring operations
 Controlling
 Guide decision
 Employee motivation
 Performance evaluation
 It is time consuming.
 Expensive
 Reports can be biased
 Sometimes implementations
of the recommendationsof a
report become unrealistic.
 Technical reports are not
easily understandable

37. NURSES RESPONSIBILITY FOR
RECORD KEEPING AND
REPORTING
• Records and reports must be functional
accurate, complete, current organized and
confidential
1. FACTS
2. ACCURACY
3. COMPLETENESS
4. CURRENTNESS
5. ORGANIZATION
6. CONFIDENTIALITY

38. 1.FACT
• Information about clients and their care must be
functional. A record should contain descriptive,
objective information about what a nurse sees, hears,
feels and smells.
2. ACCURACY
• A client record must be reliable. Information must be
accurate so that health team members have
confidence in it.
3.COMPLETENESS
• The information within a recordedentry or a report
should be complete, containing concise and thorough
information about a client care or any event or
happening taking place in the jurisdiction of manger.

39. 4. CURRENTNESS
• Delays in recording or reporting can result in serious
omissions and untimely delays for medical care or action
legally, a late entry in a chart may be interpretedon
negligence.
5. ORGANIZATION
• The nurse or nurse manager communicates information
in a logical format or order. Health team members
understand information better when it is given in the
order in which it is occurred.
6. ONFIDENTIALITY
• Nurses are legally and ethically obligated to keen
information about client’s illnesses and treatments
confidential