This presentation is for community health nursing records and reports :-
1. Definition of record and report
2. Introduction to record and report
3. Uses of record
4. Uses of records in community health nursing
5. Types of records
6. Essential requirements of records
7. Cumulative records
8. Design of cards
9.
3. RECORDS AND REPORTS
Good record-keeping is an essential and important
duty of all health personnel. This is because memories
are short, and information collected from memory can
never be reliable. Therefore records must be accurately
made at the time of the event and should be available
when required. Records and reports must be kept as
laid down by the employing authority. Records are
designed to encourage high standards of health care.
4. Uses of record
effective means of communication
helps in providing best possible service to the
individual, family and community
can save effort and money
the health worker can organize his work and make the
most effective use of his time
useful in research
can be useful as an instrument of health education
(e.g., Growth charts).
5. Types of records
The kinds of records which are normally kept will vary
with the activities. They include the following :
1. Village record
2. Family folders, household and family record and
individual health cards
3.Eligible couple records
4.Maternal and child health records(including
antenatal care, postnatal nutrition, care, childcare,
immunization)
6. Cont…
5. The tuberculosis (TB) card
6. The leprosy record
7. School health records
8. Birth and death registers
9.Outdoor attendance register
10. Operation register
11. Indoor patient register
12. Records of medical care
13. Stock registers
14. Monthly reports
15. Daily diary.
7. Essential requirements of records
they should be complete in detail
they should be accurate
they should be written in such a way that the
minimum of clerical work is involved.
they should be kept confidential. They should not be
shown or discussed with persons other than those
providing the health care.
8. Cumulative records
Cumulative records contain information gathered
over a period of time in respect of each patient in
different situations. When completed the cumulative
record (i.e.., immunization card, school health
record)reveals the whole health history of the person.
9. Design of cards
There are three designs of cards/records :
A) Folder type: It is a broad card which can be folded
into many parts say 8 or 10 pages. Some pages may be
kept blank for future entries.
(b) File type : For each patient, a file is maintained.
The outer cover of the file is usually printed with
columns for summarizing information .The periodical
data are entered in separate leaves of paper and
inserted into the file.
10. Cont…
(c) Envelope type The file type when closed on three
sides and kept open on one will form an envelope. The
data are entered on separate leaves, tagged together
and inserted into the envelope.