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Records and Reports.

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  2. 2. DEFINITION:  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 account etc. [ S.L.Geol, 2001 ] 10/24/2013 ANU JAMES 2
  3. 3.  It is a written communication that permanently documents information relevant to a client’s health care management. It is a continuing account of the client’s health care needs [ Sr. Mary lucita ] 10/24/2013 ANU JAMES 3
  4. 4. PRINCIPLES OF MAINTAINING RECORDS: Specific purpose which should be clearly understood 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. 10/24/2013 ANU JAMES 4
  5. 5. Principles of maintaining records (contnd…) Records should permit some freedom of expression. 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. 10/24/2013 ANU JAMES 5
  6. 6. Principles of maintaining records (contnd…) 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 10/24/2013 ANU JAMES 6
  7. 7.  Accuracy  Consciousness  Thoroughness  Up to date  Organization  Confidentiality  Objectivity 10/24/2013 ANU JAMES 7
  8. 8. PURPOSE OF KEEPING RECORDS: • Communication • Aids to diagnosis • Education • Documentation of continuity • Research • Legal documentation • Individual case study 10/24/2013 ANU JAMES 8
  9. 9. 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 teaching Organization of work 10/24/2013 ANU JAMES 9
  10. 10. USES OF RECORDS (contnd….) Serves as a guide for diagnosis treatment and evaluation of services indicate progress Used in research The health assets and needs of the village area 10/24/2013 ANU JAMES 10
  11. 11. TYPES OF RECORDS 1. 2. 3. 4. Patients clinical record Individual staff records Ward records Administrative records with educational value. 10/24/2013 ANU JAMES 11
  12. 12. 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 intelligently managed. c) Avoids duplication of work. d) Information for medical and legal nursing research. e) Aids in the promotion of health and care. f) Legal protection to the hospital doctor and the nurse 10/24/2013 ANU JAMES 12
  13. 13. PATIENTS CLINICAL RECORDS (contnd..) • NURSING ADMINISTRATOR’S RESPONSIBILITY?         Protection from loss Safeguarding its contents Completeness Responsibility for nurses notes. Legal value of nurses notes. Admission record. Scientific value of the nurses notes Record of order carried out. 10/24/2013 ANU JAMES 13
  14. 14. 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 personnel note 10/24/2013 ANU JAMES 14
  15. 15. WARD RECORDS. • Reducting or increase in beds. • Change in medical staff and non nursing personnel for the ward. • The introduction and pattern of support. 10/24/2013 ANU JAMES 15
  16. 16. ADMINISTRATIVE RECORDS WITH EDUCATIONAL VALUE. • • • • • Treatments. Admissions. Equipments losses and replacements. Personnel performance. Other administrative records 10/24/2013 ANU JAMES 16
  17. 17. TYPES OF RECORDS IN THE DEPARTMENT OF PUBLIC HEALTH • • • • Cumulative or continuing records Family records Registers Reports 10/24/2013 ANU JAMES 17
  18. 18. FILLING & ARRANGING OF RECORD • • • • 10/24/2013 Alphabetically Numerically Geographically With index cards. ANU JAMES 18
  19. 19. ALPHABETICALLY • Dictionary order • Encyclopaedic order 10/24/2013 ANU JAMES 19
  20. 20. Advantages and disadvantages of alphabetically arrangement system Advantages • 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 reduced • Cross reference may be avoided 10/24/2013 Disadvantages • 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. ANU JAMES 20
  21. 21. NUMERICALLY • Serial number • Digit filing GEOGRAPHICALLY Information is arranged alphabetically by geographical of place name. 10/24/2013 ANU JAMES 21
  22. 22. 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 10/24/2013 ANU JAMES 22
  23. 23. RECORD KEEEPING SYSTEM • • • • Source records Problem oriented Nursing cardex Computerized information system 10/24/2013 ANU JAMES 23
  24. 24. Computerized information system 3 major categories 1) Clinical system 2) Management information system 3) Educational system 10/24/2013 ANU JAMES 24
  25. 25. 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 happened • 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 10/24/2013 ANU JAMES 25
  26. 26. 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 subjective statements • be readable on any photocopies 10/24/2013 ANU JAMES 26
  28. 28. REPORTS 10/24/2013 ANU JAMES 28
  29. 29. DEFINITION 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 written form [ Basvanthappa bt.2009 ] 10/24/2013 ANU JAMES 29
  30. 30. DEFINITION (contnd..) 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 ] 10/24/2013 ANU JAMES 30
  31. 31. PURPOSES • 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. 10/24/2013 ANU JAMES 31
  32. 32. 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. 10/24/2013 ANU JAMES 32
  33. 33. 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 • Recommendations 10/24/2013 ANU JAMES 33
  34. 34. TYPES OF REPORTS 1. 2. 3. 4. 5. 24 hours reports Census report Anecdotal report Birth and death report Incidental report 10/24/2013 ANU JAMES 34
  35. 35. CLASIFICATION OF REPORTS BASED ON TYPES • Oral reports • Written reports 10/24/2013 ANU JAMES 35
  37. 37. ADVANTAGES AND DISADVANTAGES OF REPORTS ADVANTAGES • • • • • Monitoring operations Controlling Guide decision Employee motivation Performance evaluation 10/24/2013 DISADVANTAGES • It is time consuming. • Expensive • Reports can be biased • Sometimes implementations of the recommendations of a report become unrealistic. • Technical reports are not easily understandable ANU JAMES 37
  38. 38. NURSES RESPONSIBILITY FOR RECORD KEEPING AND REPORTING • • • • • • Records and reports must be functional accurate, complete, current organized and confidential FACTS ACCURACY COMPLETENESS CURRENTNESS ORGANIZATION CONFIDENTIALITY 10/24/2013 ANU JAMES 38
  39. 39. COMMON PROBLEMS THAT OCCUR DURING REPORT WRITING. CONTENT AND ORGANIZATION • Problem - No section headings • Problem - missing items related to the format • Problem - lack of numbering 10/24/2013 ANU JAMES 39
  40. 40. Common problems that occur during report writing.(Contnd..) GRAMMAR, VOCABULARY, SENTENCE AND TONE. OTHER PROBLEMS • Incomplete sentences • Confusing and unclear sentences. • Miscommunication • Too general • Confidentiality. • Missing information and facts. • Wordiness. 10/24/2013 ANU JAMES 40
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  42. 42. 10/24/2013 ANU JAMES 42