Records and reports

1. TEACHING PRACTICE
ON
RECORDS AND REPORTS
PRESENTED BY,
MR Zuber Shaikh
1ST YEAR MSC NURSING
MGMs MTCN,
Chh.Sambhajinagar

2. Records And Reports
• Introduction:-
• Records & reports are the good tools of
Communication in any organization to function
effeciently.
• Information are transmitted from downward to
upward & upward to downward.
• Records are documented aid to doctors, nurses &
paramedical personnels in giving the best possible
services to their clients.

3. Definition of Records & reports
• Definition of Record
• record is a permanent Written communication
that documents information relevant to client's
health care management.
OR
• "A record is a clinical, Scientific, administrative
document relating to the nursing care given to the
individual, family or community.

4. • purposes of record
1] supply data that are essential for planning &
evaluation.
2) provide the data required for the implementation
of health & nursing services for the improvement of
family health.
3) Tools of Communication between health workers
family.

5. • 4) Effective health record show the health problem in
the family and other factors that affect health
• 5] Indicates future plans
• 6) Helps in the research for improvement of nursing
Care.

6. Principles of record Writing
• 1) As record serve a legal document they Should
be written Clearly,accurately, appropriately.
• 2) all enteries should be signed by the individual
who writes them
• 3) care is to be taken not to make any errors on
the records
• 4) Record should be written in chronological
order, as to date and time .

7. • 5) Records are written continueously with no blank
spaces.
• 6) Each page of the records should be properly
identified with the Name, Age, MRD No, ward name
etc.
• 7] Records should be truthful, Complete,brief It
should include allthe Services given to patients, the
Observations made on the patien from day to day &
the result of treatment.

8. Types of records
• On the basis of clinical records they are as
follows .
1) ward records
2)Nurses records
3) Students records
4) Staff records
5) Academic and administrative records

9. • 1) Ward record
• - patient's clinical record
• - Instruction book
• - Admission records
• - Discharge record
• - Census record
• - movement register
• - vistor's record

10. • - Round register
• - Attendence record
• - Drug maintainance record
• - Death register.

11. 2) Nurses records
-Nurse's assessment sheets
- change of shift record
- Nurses report book
- Nurse's progress notes
- Treatment chart.

12. • 3) Student records
-Application forms and other reports concering
selection & admission such as references,
medical report, including mark list.

13. - Certificates & results of written test & interview at
the time of selection.
- Admission register
- A cumulative heath record.
- class attendance & leave record
- student rotation.
- practical record book
- student evaluation
- Internal practical & theory.

14. • 4) STAFF RECORDS
• It includes
• 1) Application form
• 2) Copy of appointment letter.
• 3) Job description or functions.
• 4) Records of the staff members
• i.e = educational qualification= previous experience
= Any short term educational Courses attended
participation in Seminars,
• Conferences etc.

15. • - periodic evaluation or progress report
• - Leave record
• - Health record.

16. • 5) Academic/Administrative record
1) Course Content & Course plan record for
each Subject.
2) Records of academic requirments.
3] Rotation plans for each academic years.
4) Affiliation records

17. 5) Records of the Stocks
6) Records of educational programmes organized
for teaching faculty & students
7) Annual reports.
8] statement of budget & allotments
9) Inspection record.
10] photograph/video, paper Cuttings of
important events.
11) Computerized records.

18. Reports
• Definition
• Reports are verbal or written information
shared between the health workers Reports
Summarize the activities & services of nurses.
& health care workers.

19. • Types of report
• The following are types of report.
i) verbal report
ii) written report.

20. • 1) Verbal report
• verbal reports are more convenient when the
information are for immediate use
• Sometimes emergency reports are followed by
written reports later on
• e.g: Nurse in charge of patient care reports about the
condition. of patient to the treating physician
telephonically and taking Instruction about patient
care Later on she puts in writing.

21. 2) Written reports
• Reports are written when the information has
to be used by several persons which has less
or permanent Value.
• eg:- Day and night reports, monthly report etc.

22. • Types of reports in hospital setting
The following are types Of reports used in
hospital settings .
1) change of Shift report:-
In this type of report, on duty nurse
summarize information about assigned clients
it is also known as end of shift report. This may
be given in person at the time of during rounds at
the clients bed side .

23. • 2] Transfer report
- patients will frequently be transfered from
one unit to other to receive different levels of
care.

24. Importance of records & reports
• 1) Decision Making
• - Records play an important role for making
desicion. Based on previous data, future
planning.
2 ) planning client care
- Records are very helpful for planning nursing
care to the patient

25. • 3) Communication
- Records & reports are very important for conveying
the information to the employees, employer as well
as to the public Communications of information
about clients from the nurse on sending unit to the
nurse on the receiving unit.

26. • 4) Incident report
- Incident reports are used to document any unusual
occurance or accident in the delivery of Client care.
Such as client falls, medication errors.
- 5] Legal documentation.
- Records are very helpful for the legal purposes
especially in medico legal Cases.

27. • 6) Education
- Records are helpfull for teaching the nursing and
medical Students .
• 7) Research
-Records are the secondary Source of data collection.

28. Care of records
• 1) Records are kept under safe Custody of nurse in
each word.
• 2) No individual sheet is separated from The
Complete record
• 3) Records are kept in place, which is not accessible
to the patient & family member.
• 4) No Stranger is allowed to reach record section 5)
Records are not handed over to legal advisor without
written permission of administration.

29. • 6) All records are to be handed over carefully
• 7) All records are to be arranged according to the
hospital rules,Alphabetically,Numerically
• 8] Records are never sent out of the hospital without
doctor's permission.