about records and reports

1. MAINTENANCE OF
RECORDS AND
REPORTS
Ms. Eenu, Assist. Prof.
Community Health Nursing
M.M.C.O.N, Mullana, Ambala

2. RECORDS
INTRODUTION:- The service of a
community health nurse will be meaningful only
when they are properly recorded & maintained .
The family records serve as a guide to nursing care,
as they are major practice tools today in the
community health practice. Health records also
include other information, e.g. about socio-economic,
psychological , environmental & nutritional factors.

3. DEFINITION OF RECORD
Record is written or computer based, the process of
making an entry on a client’s record is called recording,
charting, or documenting. A clinical record, also called
a chart or client record is a formal, legal document that
provides evidence of a client’s care.

4. 1- Communication… The record serves as the
vehicle by which different health
professionals who interact with a client
communicate with each other
.
2- Planning Client Care……Each health
professional uses data from the client’s
record to plan care for that client.
3- Auditing Health agencies……An audit is a
review of client records for quality
assurance purpose.
Purposes of Client
Records

5. 4- Research…….. The information contained
in a record can be a valuable source of data
for research. The treatment plans for a
number of clients with the same health
problems can yield information helpful in
treating other clients.
5- Education……. a record can frequently
provide a comprehensive view of the
client, illness, effective treatment
strategies, and factors that affect the
outcome of the illness.
- To provide the practitioner with data
required for the application of professional
services for the improvement of family’s
health
- - A record indicates plan for future

6. GENERAL GUIDELINES FOR
RECORDING
Because the client’s record is a legal
document and may be used to provide
evidence in court, many factors are
considered in recording:
1- Date and Time: document the date and time
of each recording. This is essential not only
for legal reasons but also for client safety.
Accurate according to the 24-hours clock or
in the conventional manner (am, pm).

7. 2- Timing: follows the agency’s policy about the
frequency of documenting, and adjusts the frequency
as a client’s condition indicates. No recording should
be done before providing nursing care.
3- Legibility: all entries must be legible and easy to read
to prevent interpretation errors.
4- Permanence: all entries made in dark ink so that the
record is permanent and changes can be identified.

8. 5- Correct Spelling: is essential for accuracy in
recording. Incorrect spelling gives a negative
impression to the reader and, thereby, decreases
the nurse’s credibility.
6- Signature: each recording on the nursing notes
is signed by the nurse making it. The signature
includes the name and title. For example,
SH.Qadous, RN.

9.  7- Accuracy: the client’s name and identifying information
should be stamped or written on each page of the clinical
records. Before making any entry, check that it is the correct
chart. Do not identify charts by room number only, check the
client’s name. Notations on records must be accurate and
correct. Accurate notations consist of facts or observations
rather than opinions or interpretation. It is more accurate, for
example, to write that the client” refused medication” (fact)
than to write that the client “was uncooperative” (opinion).

10. When a recording mistake is made, draw a line through it and
write the words mistaken entry above or next to the original
entry, with your initials or name. Do not erase, or use
correction fluid. Write on every line but never between lines.

11. 8- Sequence: document events in the order in which they occur,
such as record assessments, then the nursing interventions, and
then the client’s responses.
9- Appropriateness: records only information that pertains to the
client’s health problems and care. Recording irrelevant
information may be considered an invasion of the client’s
privacy.

12. 10- Completeness: not all data that a nurse obtains about a client
can be recorded; however, the information that is recorded
needs to be complete and helpful to the client and health care
professionals. Nurse’s record need to reflect the nursing
process, record assessment, dependent and independent nursing
interventions, client problems, client comments and responses
to interventions and tests, progress toward goals.

13. 12-Conciseness: recording need to be brief as well as complete
to save time in communication.
13. Accepted Terminology: Use only commonly accepted
abbreviations, symbols, and terms are specified by the agency.
Many abbreviations are standard and used universally.

14. 13- Legal Prudence: accurate, complete documentation
should give legal protection to the nurse, the client’s
other caregivers, the health care facility, and the client.
“Complete charting for example by using the steps of the
nursing process as a framework, is the best defense
against malpractice.”

15. VALUE AND USE OF
RECORDS
FOR A NURSE -:
 The record provide basic facts for
services.
 Provides a basis for analyzing the
needs in terms of what has been done,
what is being done ,what is to be done
 Provides a basis for short & long term
planning .
 It serves as a guide to professional
growth.
 It enable the nurse to judge the quality
& quantity of work done .

16. FOR THE FAMILY AND INDIVIDUAL:-
 The record help to become aware of & to recognize
their health needs .
 A record can be use as a teaching tool too.
 The health records or any investigations done any
investigations done in any other institutions will be
helpful for an effective diagnosis and treatment.

17. FOR THE DOCTOR:-
 The record serve as a guide for diagnosis , treatment &
evaluation of services.
 It indicate progress of the patient and continutiy of
care.
 It may be use in research.

18. FOR THE ORGANISATION AND COMMUNITY:-
 The record help the supervisor to evaluate the
services.
 It help in guidance of staff & students.
 Help in research.
 It provide a justification for expenditure of funds.
 It helps the administration in assessing the
performance of their own institutions and the needs of
the society.

19. TYPES OF RECORDS

20. 1.FAMLY RECORDS:-
The family folder which contain all the individual record
of one family.
All the record which relate to members of one family
should be placed in the single family folder. In this
way the doctor & health workers can see the total
situation & give effective economical service to help
the family as a whole.

21. 2. ANECDOTAL RECORDS:-
It is a brief description of an observed behavior that
appears significant for evaluation purposes, done by
community health nurse during home visit.
3. CLINICAL RECORD:- It is used in the hospital;
investigations special treatments & procedures written
& sign.

22. 4. DOCTORS ORDER SHEET:-
Doctor order regarding medications , investigations,
special treatments & procedures written & signed.

23. 5.NURSES SHEET :-
Nurses notes are a record of treatments & nursing
measures carried out by the nurses , their effect
the observations made on the patient.

24. OTHER RECORDS:-
TPR chart, lab report sheet, diet sheet, intake output
chart, anesthesia chart, physiotherapy sheet, special
treatment sheets etc.

25. Progress Notes
Is a chart entry made by all health professionals involved in a
client’s care, they all use the same type of sheet for notes. For
example, the SOAP format is frequently used.
S – Subjective data consist of information obtained from what the
client says. It describes the client’s perceptions of and
experience with the problem.
O – Objective data consist of information that is measured or
observed by use of the senses(e.g., V/S , Lab test, X-ray
results).

26. A – Assessment is the interpretation or conclusions drawn
about the subjective and objective data. ’’A’’ should
describe the client’s condition and level of progress
rather than merely restating the diagnosis or problem.
P- Plan is the plan of care designed to resolve the stated
problem.

27. The SOAP format has been modified to SOAPIER
I- Interventions refer to the specific interventions that have
been performed by the caregiver.
E- Evaluation includes client responses to nursing
interventions and medical treatments.
R- Revision reflects care plan modifications suggested by
the evaluation.

28. Registers maintains the statics. In al community
health centers, hospital system &educational
institutions maintain registers.
IN HOSPITAL
birth & death register
census register
admission , discharge register
OPD register, stock register
REGISTERS

29. IN COMMUNITY
Immunization register
Health care register
Clinic attendance register
Family planning register
Birth & death register
Surveillance register ,stock register

30. CONTD…
 Stock register
 Mother care register
 Monthly report register
 General information register
 School health register
 Eligible couple register

31. REPORTS

32. INTRODUCTION
 Reporting is the verbal or written communication
of data regarding the client’s health status,
needs, treatments, outcomes & responses.
 It facilitates clinical decision making, continuity
of care & coordination among the health team
members.

33. DEFINITION
 Report is an oral or written account by one
member to another in the health team which
includes the end of shift handing over the report.
 It offers a summary of activities or observation
seen, performed or heard which is exchanged
among health care team members, clients &
family members.

34.  For giving concise, efficient & organized report
nurse must think about-
 what needs to be said?
 why it need to be said?
 how to say?
 what the expected outcomes are?

35. IMPORTANCE OF REPORTS
 A complete report establishes the nurse’s
accountability in being sure that the client’s care
is uninterrupted.
 It provides a baseline for comparison during the
next shift.
 It shares significant information about family
members as it relates to client’s problem.

36. CONTD…….
 It evaluates results of nursing & medical care
measures.
 It relates to staff significant changes in the way
therapies are given.

37. ELEMENTS
 Timings
 Organisation
 Clarity
 Brevity
 Correctness
 Objectivity

38. PURPOSES OF WRITTEN REPORTS
 To show the kind & amount of services rendered
over a specified period.
 It helps to illustrate progress in reaching goals.
 It acts as an aid in studying health condition.
 It aids in planning.
 It helps to interpret the services to the public &
to other interested agencies.

39. 1) Oral reports – It is sometimes used in
emergency & followed by a written
report later.
An oral report is made by the nurse who
is assigned to patient care , to the
another nurse who is supposed to relieve
her.
2) Written reports - It should concentrate
on the past, present & future state of
the patient . Description & conclusion of
the state influences further planning &
decision making. Daily, weekly, monthly
& annual reports are its further types.
Types

40. CONTD…..
3) 24 hours report – It keeps nursing supervisor
& nursing administrative personnel informed of
what is happening in all patient care areas.
4) Census report – It includes the daily census
or the no. of patients admitted in the hospital.
This report helps in planning of health care
services & knows about the morbidity &
mortality statistics.

41. 5) Accidental reports – It includes
writing a detailed report on
mistakes or accidents that has
taken place in the care of
pateint’s. It should be promptly
informed to the higher authorities
by writing accidental reports.
6) Change of shift report – At the
end of each shift, nurse’s report
information about their assigned
clients to the nurses working on
the next shift.

42. 7) Transfer report – It involves communication of
information about client from nurse to the nurse on the
receiving unit.
8) Telephone Reports- health professionals frequently about a
client by telephone. Nurses inform primary care providers about
a change in a client’s condition.
- The nurse receiving a telephone report should document the date
and the time, the name of the person giving the information, and
the subject of the information received.
- The person receiving the information should repeat it back to the
sender to ensure accuracy.

43. - When giving a telephone report to a primary care
provider, begin with name and relationship to the client.
For example “This is Maher , RN, I’m calling about your
client, jhon. I’m her nurse on the 7pm to 7am shift’’.
- Telephone reports usually include the client’s name and
medical diagnosis,…ect. The nurse should have the
client’s chart ready to give any further information.

44. 9) Telephone Orders - physicians often order a therapy for a
client by telephone. While the primary care provider gives the
order, write the complete order down and read it back to ensure
accuracy. Question about any order that is ambiguous, unusual, or
contraindicated by the client’s condition.

45. 10) Nursing Rounds - procedures done to:
- Obtain information that will help plan nursing care
- Provide clients the opportunity to discuss their care
- Evaluate the nursing care the client has received.
During rounds, the nurse assigned to the client provides a
brief summary of the client’s nursing needs and
interventions being implemented.

46. ROLE
OF
NURSE

47. CARE OF DOCUMENTS:-
 It should kept under the safe custody of nurse in each
ward.
 No individual sheet is separated from the complete
record.
 It should kept in a place ,not accessible to the patients
& visitors.
 It are never sent out of the hospital without doctor’s
permission.
 Handle the documents carefully

48. SECURING DOCUMENTATION INFORMATION:-
 The nurse & individual should be comfortably
seated in a private quite area so that confidential
information can be given & kept at professional
level.
 Write brief notes of every visit showing:-
-Explain the reason for making the
record.
-Particular observation made
-Evidence of benefit to family .
-plan for next visit.
-Referrals.

49. FILLING OF RECORD:-
 It should be correctly filled.
 these are set up &maintained in a systematic planned
& organized manner.
 Can be arranged alphabetically & numerically.