6. Record
•Memory of the internal and
external transactions of an
organization.
•Contain written evidence of the
activities of an organization.
7. Recording
• A written communication that permanently documents information
relevant to a client’s health care management.
• It is a continuing account of the clients health care needs.
-Sr. Mary Lucita
8. Reporting
• Keeping those to whom the executive is responsible informed as to
what is going on, which thus includes keeping himself and his
subordinates informed through records, research and inspections
10. Importance of Recording
1. Structures and clarifies complex information and interpretation.
2. Supports information gathering, assessment and decision making.
3. Focuses practitioners and their work.
4. Forms the basis for reports .
5. An element for professional accountability.
6. Provides a major source of evidence for inspection, investigations
and inquires.
7. Record provides basic facts for services.
8. This system helps in cutting down unnecessary costs.
11. Importance of Reporting
1. Reporting provides a basis for short and long term planning.
2. Serves as a guide to professional growth.
3. Indicates progress.
4. May be used in research.
5. Helps in the guidance of staff.
6. Works as the vehicle for public reporting.
7. The report can be used in placing surveillance on potentially large
scale disease outbreak.
12. Techniques of Report writing
1. Determine the objective of the report, i.e. identify the problem.
2. Collect the required material (facts) for the report.
3. Study and examine the facts gathered.
4. Plan the facts for the report.
5. Prepare an outline for the report, i.e. draft the report.
6. Edit the drafted report.
7. Distribute the draft report to the advisory team and ask for feedback
and recommendations.
13. Features of a good report
The essentials of good/effective report writing are as follows-
1. Know your objective, i.e. be focused.
2. Decide the length of report.
3. The report should be neatly presented and should be carefully
documented.
4. Decide on the margins on a report. Ideally, the top and the side
margins should be the same (minimum 1 inch broad), but the
lower/bottom margins can be one and a half times as broad as others.
14. Features of a good report contd…
5. Report must be complete.
6. Report must be written in sequential order.
7. Report must be understandable.
8. Report must be delivered timely.
9. Jargons should be avoided.
15. Format of a Report
• Title Section – This includes the name of the author(s) and the date of
report preparation.
• Summary – There needs to be a summary of the major points, conclusions,
and recommendations. It needs to be short as it is a general overview of the
report.
• Introduction – The first page of the report needs to have an
introduction. You will explain the problem and show the reader why the
report is being made.
• Body – This is the main section of the report. There needs to be several
sections, with each having a subtitle. Information is usually arranged in
order of importance with the most important information coming first.
16. Format of report contd…
• Conclusion – This is where everything comes together. This section
should be free of jargon as most people will read the Summary and
Conclusion.
• Recommendations – This is what needs to be done.
Recommendations are put in order of priority.
• Appendices – This includes information that the experts in the field
will read. It has all the technical details that support the conclusions.
17. Contents of a Report
1. Title page
2. Table of contents: It lists the contents of a report.
3. Executive summary:An executive summary is a brief overview of a report
that is designed to give the reader a quick preview of the report's
contents.
4. Introduction: The introduction should briefly describe the context and
background and should define the specific objectives and purpose of the
report.
5. Discussion: This is the main body of the report. It present the analysis in
a logical and systematic way. If necessary, divided with appropriate
headings to improve the readers' understanding.
18. Contents of a Report contd…
6. Conclusion: It identifies the major issues relating to the case and
interpretation of them is given.
7. Recommendations: Recommendations should point to the future
and should be, action-oriented, feasible, logically related to the
discussion and conclusion, arranged in order of importance.
8. References: The reference section comprises a list of all sources that
were cited in the text.
9. Appendices: It includes any essential extra material, such as tables
pictures etc.
19. References
• Records and reports, currentnursing.com.
• Management of health records, www.cdc.gov.