ANU JAMES. MSc (N)
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
[ S.L.Geol, 2001 ]
permanently documents information relevant
to a client’s health care management. It is a
continuing account of the client’s health care
[ Sr. Mary lucita ]
PRINCIPLES OF MAINTAINING
Specific purpose which should be clearly
Items on forms and in registers should be
conveniently grouped so as to make their
completion as easy as possible.
The wording should be easily understood, and
where doubt is likely to arise, instructions to
facilitate interpretation should be included.
Principles of maintaining records
Records should permit some freedom of
Records which are required by the teaching
staff should be easily accessible to them.
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.
Principles of maintaining records
Provision for periodic review of all records to
ensure that they keep pace with the changing
needs of the programme.
Adequate supply of stationery to permit records
to be maintained on the proper forms and in the
proper registers at all times.
Sufficient number of filing cabinets and
appropriate equipments to operate a filing
system which is simple and safe and requires the
minimum possible time.
Adequate, safe, fireproof storage arrangements
Up to date
PURPOSE OF KEEPING RECORDS:
• Aids to diagnosis
• Documentation of continuity
• Legal documentation
• Individual case study
USES OF RECORDS
Show the health conditions as it is and as the
patient and family accepts it.
goals towards which means are to be directed.
prevents duplication of services and helps follow
up services effectively.
Helps the nurses to evaluate the care and the
Organization of work
USES OF RECORDS (contnd….)
Serves as a guide for diagnosis
treatment and evaluation of services
Used in research
The health assets and needs of the
TYPES OF RECORDS
Patients clinical record
Individual staff records
Administrative records with educational
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
c) Avoids duplication of work.
d) Information for medical and legal nursing
e) Aids in the promotion of health and care.
f) Legal protection to the hospital doctor and the
PATIENTS CLINICAL RECORDS (contnd..)
• NURSING ADMINISTRATOR’S RESPONSIBILITY?
Protection from loss
Safeguarding its contents
Responsibility for nurses notes.
Legal value of nurses notes.
Scientific value of the nurses notes
Record of order carried out.
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
• Reducting or increase in beds.
• Change in medical staff and non nursing
personnel for the ward.
• The introduction and pattern of support.
ADMINISTRATIVE RECORDS WITH
Equipments losses and replacements.
Other administrative records
TYPES OF RECORDS IN THE
DEPARTMENT OF PUBLIC HEALTH
Cumulative or continuing records
FILLING & ARRANGING OF RECORD
With index cards.
• Dictionary order
• Encyclopaedic order
Advantages and disadvantages of
alphabetically arrangement system
• Most people are familiar
• Staff should be able to learn
and become comfortable with
the system in a timely manner
• The need to shift the records
after purging records is
• Cross reference may be
• system does not work well
with very large filing systems
• Color coding is more difficult
since you need to have 26
colors or combination of
colors to designate all the
letters of the alphabet
• Confidentiality is an issue
• Some of the rules of alpha
filing can be very confusing.
• Serial number
• Digit filing
Information is arranged alphabetically
by geographical of place name.
WITH INDEX CARDS
• An index card consists of heavy paper cut to a
standard size, used for recording and storing
small amounts of discrete data. It was
invented by Carl Linnaeus, around 1760.
Eg:- forms, case records and registers.
Diaries- diary of M & F
Return – monthly report of HW (M& F)
In addition each organization should maintain
• Cumulative records
• Family records
RECORD KEEEPING SYSTEM
Computerized information system
Computerized information system
3 major categories
1) Clinical system
2) Management information system
3) Educational system
GUIDELINES FOR DOCUMENTATION
AND RECORD KEEPING
The Nursing and Midwifery Council (NMC 2002)
has said that patient and client records should:
• be based on fact, correct and consistent
• be written as soon as possible after an event has
• be written clearly and in such a way that the text
cannot be erased
• be written in such a way that any alterations or
additions are dated, timed and signed, so that the
original entry is still clear
GUIDELINES FOR DOCUMENTATION AND
RECORD KEEPING (contnd..)
• be accurately dated, timed and signed, with
the signature printed alongside the first entry
• not include abbreviations, jargon meaningless
phrases, irrelevant speculation and offensive
• be readable on any photocopies
IMPORTENCE OF RECORDS IN
HOSPITAL OR HEALTH CENTERS.
INDIVIDUAL AND FAMILY
FOR THE DOCTOR
FOR THE NURSE
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
[ Basvanthappa bt.2009 ]
Reports are oral or written
exchanges of information shared between
care givers of workers in a number of ways.
A report summarises the service of the
personnel and of the agency
[ Jean b. 2002 ]
• Report is an essential tool to communication
• To show the kind and amount of services
rendered over a specific period.
• To illustrate progress in teaching goals.
• As an aid in studying health condition.
• As an aid in planning.
• To interpret the services to the public and to
the other interested agencies.
CRITERIA FOR A GOOD REPORT
• made promptly.
• clear, concise, and complete.
• 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.
• It is clearly stated and well organized
• Important points are emphasized.
• In case of oral reports they are clearly expressed
and presented in an interesting manner.
REPORTS IN NURSING EDUCATION
• Factual data related to the students, staff,
clinical facilities, physical facilities,
administration and the curriculum
• Development made in the school programme
since the last report.
• Proposal and plans for future development.
• Problems encountered
TYPES OF REPORTS
24 hours reports
Birth and death report
CLASIFICATION OF REPORTS BASED
• Oral reports
• Written reports
REPORTS USED IN HOSPITAL
CHANGE – OF – SHIFT REPORTS
ADVANTAGES AND DISADVANTAGES
• It is time consuming.
• Reports can be biased
• Sometimes implementations
of the recommendations of a
report become unrealistic.
• Technical reports are not
NURSES RESPONSIBILITY FOR RECORD
KEEPING AND REPORTING
Records and reports must be functional
accurate, complete, current organized and
COMMON PROBLEMS THAT OCCUR
DURING REPORT WRITING.
CONTENT AND ORGANIZATION
• Problem - No section headings
• Problem - missing items related to the
• Problem - lack of numbering
Common problems that occur during
GRAMMAR, VOCABULARY, SENTENCE AND TONE.
• Incomplete sentences
• Confusing and unclear sentences.
• Too general
• Missing information and facts.