Communication refers to the reciprocal exchange of information between individuals through verbal and nonverbal means. It serves several purposes in healthcare, including collecting assessment data, initiating and evaluating interventions, and analyzing factors affecting the health team. Records document relevant health information and come in various types, like medical records and family records. They supply essential data for planning, provide a baseline, and indicate future plans. Reports summarize activities, observations, and the progress toward goals over a specific time period and also aid in studying health conditions and planning. Characteristics of good records and reports include timeliness, permanence, completeness, signatures, confidentiality, and accuracy.
2. Introduction
The term communication is derived from
the latin word “communis” meaning
common.
In general, communication refers to the
reciprocal exchange of information,
ideas, facts, opinions, beliefs, feelings &
attitudes through verbal or nonverbal
means between two people or within a
group of people.
3. Definition
Communication is a process by which information is
exchanged between individuals through a common
system of symbols & signs of behavior - Webster’s
Dictionary
Communication is interchange of thoughts, opinions or
information by speech, writing or signs - -Robert
Andersion
4. Purpose of Communication
To collect assessment data
To initiate intervention
To evaluate outcome of intervention
To initiate change which helps in promoting health
To analyze factors affecting the health team
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39. Records
“A record is a permanent written communication that
documents information relevant to a clients health care
management” – Potter and Perry
E.g. client chart is a continuing account of client’s health care
status and need.
40. Purposes of records
Supply data that are essential for program planning and evaluation.
To provide the practitioner with data required for the application of
professional services for the improvement of family’s health.
Records are tool of communication between health care workers , the
family and other development personnel.
A records indicates plans for future.
It provide baseline data to estimate the long term changes related to
services.
41. Types of Record
Cumulative or continuing records – it is helpful for review the
total history of an individual and evaluate the progress of a
long time period.
Family record
Ward record
Medial / nursing record
Student record
Staff record
Academic / administrative record
42. Reports
“Reports are the information about a patient either written or oral”
(Sr.Nancy)
“A reports is a summary of activities or observation seen ,
performed or heard” (Potter and Perry)
Purpose of reports -
To show the kind and quantity of services rendered over to a specific
period.
To show the progress in reaching goals.
As an aid in studying health conditions.
As an aid in planning
43. Types of reports
Change of shift report – it is a report given to all nurses
on the next shift.
Telephone report – health professionals frequently
about a client by telephone.
Transfer report
Incident report - occurrence reports are to used to
document any unusual occurrence or accident in the
delivery of client care.
Legal report
44. Characteristic of good record
and report-
Timing
Permanency
Completeness
Signature
Confidentiality
Accuracy
Use of standard terminology
45. Nurses responsibility for
record keeping and reporting
Keep under safe custody of nurses
Not accessible to patients and visitors
Records are not handed over to the legal advisors
without written permission of the administration
Handed carefully , not destroyed
Identified with bio-data of the patients such as name ,
age , admission number , diagnosis etc.
Never sent to the outside of the hospital without the
written administrative
Accurate recording and reporting of all abnormal mode
signs and symptoms observed.