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RECORDS
AND
REPORTS

OBJECTIVES
.
TO KNOW ABOUT THE RECORDS
TO DISCUSS ON REPORTS
TO TELL ABOUT LEGAL IMPLICATIONS
OF REPORTS
ROLE OF NURSE IN RECORDING

RECORDS

DEFINITION
A record is a permanent written
communication, that documents
informations which is relevant
to a client’s health care
management.

PRINCIPLES
Be Written clearly
Understandable.
Be completed and
should give accurate
information.
Be filed serially
numbered and properly
arranged.
True facts based on
observation,conversation
and action.
Continuity should be
maintained.
Always be printed.

Be written
immediately
after service.
Be kept
confidential.
Not be kept
blank.
CONT..

TYPES OF RECORDS
A. CLINICAL RECORDS
-Handwritten clinical notes
-Electronic health records
-E-mails
-Official letters from top level
health management team
-Laboratory reports and X-rays
-Anecdotes
-Photographs
-Audio visual media
(audio and video tapes,
digital recordings,CDs,DVDs)
-Tape recordings of telephone
conversation
-Text messages
B. MANUAL RECORDS
-Newborn health record
-Preschool health record
-Immunisation record
-Antenatal health record
-Postnatal health record
-Morbidity record

REGISTERS
MAINTAINED BY
STAFF NURSE/ANM
-Nurse report book
-TT injection register
-Antenatal clinic register
-Postnatal clinic register
-IUD registers
-Under 5 clinics registers
-Laundry register
REGISTERS MAINTAINED
BY VILLAGE HEALTH
NURSE
-Family and eligible couple
register
-Mother care register
-Child care registers
-Minor ailments treatment
registers
-Referral register
-Drug stock register
-NRHM related activites
register

REGISTERS
MAINTAINED BY MALE
HEALTH WORKER
-Family register
-Disease surveillance register
-Program register
-School health register
-Inspection register
-Drugs,equipement registers
-Birth and death issue register
-Tobacco control activity related
registers
-Register of vital statistics
-Weekly review register
-Report on inspection and case sheets
SCHOOL HEALTH
PROGRAM
-Student health appraisal register
-Referral slip and follow up
register
-Home visit register
-Monthly activity report

USES OF
RECORDS

A. FOR NURSES
● The record provides the services done- what is being
done, what is to be done and the goals to be achieved toward
health.
● Record provides basis for planning the interventions.
● Record prevents duplication of services and helps
follow-up services effectively.
● Record helps the nurse to organise her work and saves
time.
● Record serves as a guide to professional growth.

B. FOR DOCTORS
● The record serves as a guide for diagnosis and
treatment, follow-up, and evaluation of services.
● Records indicate progress of the patient and
continuity of care.
● Records protect the doctor in case of legal issues.
● Records used for a doctor in teaching, research
and medical practice.

C. FOR HEALTH AGENCY
● The record helps the administrator in assessing the
performance of their own institutions and the needs of the
society.
● The record helps in making studies for research, for
legislature action and for planning budget.
● Record provides a justification for expenditure of funds.
● Record helps in the guidance of staff, students, employees
and other categories.
● Planned records are utilised as an evaluation tool during
conferences and meetings.
● Records provide quality and quantity of their services.

D. FOR A HEALTH WORKER
AT VILLAGE LEVEL
● The record will help the nurse to know about the details of pregnant
women making use of antenatal services such as registration, history,
TT, immunisation, feeding, high- risk conditions, antenatal examination
and the future plan for delivery and condition of fetus, etc. (MCH
Registers).
● The mother care register provides the details of delivery conducted,
by whom, sex of the baby, place of delivery, birth weight, etc.
● The birth and death register provides the number of births and
deaths in a day, month and year, causes of death.
● Referral register provides the details of the referred cases.
● Child care register provides information about immunisation, date of
birth, age, sex, place of birth and birth weight, etc.
● Growth chart provides weight taken, grading of malnutrition, height
and sickness, etc.

E. FOR THE FAMILY AND
INDIVIDUAL
The records help the individual and family
to become aware of their health needs.

ROLE OF COMMUNITY HEALTH
NURSE
● Be written clearly, legibly in non-erased material and must
be dated with time and signature.
● The signatory's name designation/role must be written in
the record.
● Records must be factual, complete, consistent, accurate
and consecutive.
● Avoid complicated jargon.

● Record only relevant and useful information.
● Do not overwrite or use erasers or fluid to cancel errors.
● It should be visible, readable when photocopied or scanned.
● Keep records securely and confidentially.
● Store under lock and key.
● Care must be taken to secure confidentiality of electronic
records; specifically when it is shared or transferred.

RETENTION AND DISPOSAL
OF RECORDS
RECORD AUDITING

REPORTS

DEFINITION
Report is oral or written
exchange of information
shared between health team.

PURPOSE
To show the amount of service rendered over a specified period.
It acts as an aid in studying health conditions.
It acts as an aid in planning.
Good reports are time saver.
Prevent duplication of work..
Provide a sense of security and confidence to the nurse in doing her
work.

ELEMENTS
FACT
CURRENTNESS ORGANIZATION
COMPLETENESS
CONFIDENTIALITY
ACCURACY

TYPES OF REPORTS
24 HOUR REPORT
➢ Provide only essential background
information about client (name, age sex,
diagnosis and medical history)
➢ Identify clients' nursing diagnosis or
health care problems and other related
causes.
➢ Describe objective measurements or
observations about clients' condition
and response to health problems.
➢ Share significant information about
family members, as it relates to clients'
problems.
➢ Continuously review ongoing discharge
plan.
TRANSFER REPORT
A transfer reports involve communication
of information about clients from the
nurse on sending unit to the nurse on the
receiving unit. Nurse should include the
following information.
➢ Client's name, age, primary doctor,
and medical diagnosis.
➢ Summary of medical progress up to
the time of transfer.
➢ Current nursing diagnosis or
problems and care plan.
➢ Any critical assessment or
interventions to be completed shortly.

INCIDENT REPORTS
➢ The nurse who witnessed the
incident or who found the client at
the time of incident should file the
report.
➢ The nurse describes in concise what
happened specifically objective
terms, etc.
➢ Any measures taken by the nurse,
other nurses, or doctors at the time
of the incident are reported.
➢ The report is submitted as soon as
possible.
➢ The nurse should never make
photocopy of the incident report.

. CENSUS REPORT
This is a report compiled daily for the
number of patients. Very often it is
done at midnight and the norms are
collected by the night supervisor. The
report will show the total number of
patients,the number of admissions,
discharges, transfers, births and
deaths. The nurses should remember
that a single mistake in the census
figures made by one of the nurses
make the census report of the entire
institution incorrect.

BIRTH AND DEATH REPORTS
The nurses are responsible for sending the birth and death reports to
governmental authorities for registration within the specified time.

An anecdote is brief
account of some incident.
Incident reports and
reports on accidents,
mistakes and complaints
are legal in nature.
A written record concerning
some observation about a
person or about her work is
called an anecdote note.

LEGAL IMPLICATION IN
MAINTAINING RECORDS
➔Prescription of drugs by the physicians for
treatment and care of the patient.
➔Registration of births, deaths and stillbirths are
the important vital events.
➔Medicines should be administered as per the
order of physician and also under supervision.
➔Checking the labels of drug and it should also be
charted accurately before administration.

➔Informed consent is essential before surgery or
investigation of the patients.
➔Identification of babies in labor ward by labels.
➔Identification of dead bodies in mortuary.
➔Reporting of accidents, incompetent behaviours.
errors.
➔Confidentiality in record working and
maintenance.

Maintaining good quality
records and reports has
both immediate and long-
term benefits for staff. In
the long term it protects
individuals and teams
from accusations.

ASSIGNMENT
Why proper records and
reports are important in
health field?

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