B.Sc NURSING IV YEAR

1. PRESENTED BY:
MRS. DEVA PON PUSHPAM.I,
ASSISTANT PROFESSOR.
MAINTENANCE OF HEALTH
RECORDS FOR SELF AND
FAMILY

2. INTRODUCTION
 Community health nurses who live in the community
and learn with the community on many issues that
may come to her way.
 She is bound to answer on care and follow up
services of the community assigns for her.
 One of the most important tasks of the community
health nurse is the maintenance of records and
reports for the population she serves.

3. RECORDS
 Health records refer to the forms on which
information about an individual or family is
recorded.
 Records present facts, data, figures or other
information in writing is called records.
 Records work as an evidence of activities.
 It also indicates the plans for the future visits in
order to help the family member to meet the needs.

4. Salient features:
 Records consists of health problems and needs of
individual.
 Measures (preventive and promotive and
rehabilitative) taken so far.
 Cultural beliefs, attitudes and practices of the
individual and family that provides a platform to
plan for health education.
 Records also help us to reinforce health teaching if
needs felt or observed.

5. Purposes:
 Supply data that are essential for programme planning and
evaluation for staff member, administrator or any other
members.
 To provide the practitioner with data required for the
application of professional services for the improvement of
family’s health.
 Records are tools of communication between health workers,
the family and other development personnel.
 Effective health record shows the health problem in the family
and other factors that affect health.
 Indicates plan for future action.
 Provides baseline data to estimate the long term changes
related to services.
 Its a legal document of service providing agency.
 Communication tool between health worker, family and other
personnel.

6. Importance:
 Assessing the health of the community.
 Collecting statistics needed for health authorities.
 Attention of the doctor or other members of the
health team to specific needs of individuals or
families and for follow up services.
 Information of supervisors in assessing work done.
 Assessing need for various drugs, transport, etc.
based on numbers and types of patients.
 A tool for health education of individuals, families
and communities.
 Evaluating progress of the health programmes.

7. Principles of records:
 Clearly identify the client by name and identification number
or date of birth on each page of the record.
 Each side of the page should be numbered.
 Contacts should be mentioned in record either direct or
indirect.
 Record should be factual, consistent and accurate.
 Record should be written clearly and legibly in such a manner
that the text cannot be erased.
 Date and time should be mentioned in the record.
 Be signed with the signature printed alongside each entry,
together with professional status.
 Any alterations or additions are dated, timed and signed.
 Record should be based on subjective statements.

8. Types of records:
1. Periodical records
 Permanent records (cumulative)
 Temporary records (casual / daily)
2. Unit based records
 Individual health records
 Family records (family folders)
 Community records (community folders)
 National (National Health Programmes records)
3. Subject based records
 Economical (financial structure of family, village)
 Social record (records of social structure)
 Political records
 Medical and nursing (treatment and medicine records)

9. Contd.,
4. Collection place based records
 Collected at institutions (hospitals and health
centres)
 To be kept with the individual (immunization
cards, disease cards)
5. Family health records
Family folder
Individual health record
Cumulative record
Register

10. Records maintained in subcentre:
 Village records (general information about the village)
 Family folder and individual health cards
 Eligible couple register
 Record of contraceptives distributed
 MCH records (antenatal care, child care, nutrition and immunizations)
 Records of distribution of iron and folic acid and vitamin A solution
 Vital events register
 Stock register for receipt, issue and balance of drugs, contraceptives,
stationery, etc.
 Records of medical care and referral
 Inventory of furniture, linen and equipment
 Records of meetings with village health guides and dais, co-workers and
supervisors.
 Monthly reports and other periodic reports as and when required
 Daily diary
 Maps, charts and graphs.

11. Maintenance of records:
 Record must be kept carefully and in clean conditions,
safe from rats and insects.
 Records should not be lost or misplaced.
 Records are confidential and should be shown only to
authorize persons.
 Maintaining good system of filling (alphabetically,
numerically, geographically and with index card)
 Records should be divided into localities and filed in
order of house numbers.
 Records should have a register or index cards filled in
alphabetical order of the heads of the families.
 Records must be readily available and kept up to date.

12. REPORTS
 Reports are oral or written exchanges of information
shared between care givers or workers in a number
of ways.
 A report summarizes the services of the person or
personnel of the agency.
 Reports are usually written daily, weekly, monthly or
yearly.

13. Purposes of reports:
 To show the kind and amount of services rendered
over a specified period.
 To illustrate in reaching goals.
 As an aid in studying health conditions.
 As an aid in planning.
 To interpret the services to the public and to the
other interested agencies.
 They save duplication of efforts and eliminate the
need for investigation to learn the facts in situation.

14. Types of reports:
1. Oral reports:
Oral reports are given when the information is for immediate
use and not for permanency. Eg., staff nurse to the relieving
nurse or supervisor or doctor.
2. Written reports:
Reports are to be written when the information is to be used
by several personnel, which is more or less permanent value.
Eg., day and night reports, census, etc.

15. Reports at sub centre setting:
 Monthly sub centre reports
 Weekly sub centre reports
 Annual list of eligible and target couples
 List of births or deaths
 Report on the utilization of disposable delivery kits
 List of malaria slides

16. Factors to be considered in record keeping
and reporting:
Factors
Fact
Accuracy
Completeness
Current
Organized
Confidentiality

17. THANK YOU