record

1. RECORDS AND
REPORT
S

2. DEFINITION:
 Records are 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, contracts,
vouchers, minutes of meeting, books of account etc.
[ S.L.Geol, 2001 ]

3.  It is a written communication that permanently
documents information relevant to management or
any organization .
[ Sr. Mary lucita ]

4. PRINCIPLES OF MAINTAINING
RECORDS:
Specific purpose should be clearly understood.
Items on forms and in registers should be
conveniently grouped so as to make their
completion as easy as possible.

5. PRINCIPLES OF MAINTAINING
RECORDS:
Follow SMART formulae.
The wording should be easily understood,
and where doubt instructions to facilitate
interpretation should be included.
Every effort should be made to keep records
up to dated, accurate and signed.
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6. Principles of maintaining
records (cont…)
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
Record to be maintained on the proper forms and in
the proper registers at all times.
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7. Principles of maintaining
records (contnd…)
Appropriate equipments to operate a filing system
which is simple and safe and requires the minimum
possible time should be made available.
Adequate, safe, fireproof storage arrangements
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8. CHARACTERISTICS OF GOOD RECORDING
 Accuracy
 Consistent
 Thoroughness/complete
 Up to date
 Organized
Specific
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9. • Communication
• Aids to diagnosis of problem
• Documentation of continuity
• Research
• Legislative use
PURPOSE OF KEEPING RECORDS:

10. Prevents duplication of services and helps
follow up services effectively.
Helps to evaluate the progress.
Organization of work
PURPOSE OF KEEPING RECORDS
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11. GUIDELINES FOR RECORD
KEEPING
• 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 .
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12. GUIDELINES FOR RECORD KEEPING
• be accurately dated, timed and signed, with the
signature .
• be written in such a way that any alterations or
additions are dated, timed and signed, so that the
original entry is still clear
• not include abbreviations, meaningless phrases,
irrelevant and offensive statements
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13. IMPORTENCE OF RECORDS
IN HOSPITAL, COMMUNITY
AND HEALTH AGENCY.

14. - Serve the history of the client
- Assist in continuity of care
- Evidence to support if legal issues arise
- Assess health needs, research and teaching.

15. Importance of Records in
Hospital
For doctors
- Serve the guide for diagnosis, treatment, follow-up
and evaluation.
- Indicate progress and continuity of care.
- Self-evaluation of medical practice
- Protect doctor in legal issues
- Used for teaching and research

16. 3. For the nurses:
- Document nursing service rendered
- Shows progress
- Planning and evaluation of service for future
improvement
- Guide for professional growth
- Judge the quality and quantity of work done
- Communication tool between nurse and other staff
involved in the care.

17. 4. For authorities:
- Statistical information
- Administrative control
- Future reference
- Evaluation of work in terms of quality, quantity and
adequacy.
- Help supervisor to evaluate service
- Guide staff
- Legal evidence of service render by each employee
- Provide justification of expenditure of funds.

18. REPORTS
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19. REPORTS
• A report is usually a piece of factual writing , based on
evidence , containing organized information on a
particular topic .
• Reports can be oral or written depending upon the
mode of presentation .
A report is a summary of activities or observations seen,
performed or heard.
-Potter and Perry

20. • Reports can be compiled daily, weekly, monthly,
quarterly and annually.
• Report summarizes the services of the nurse and/ or the
agency.
• Reports may be in the form of an analysis of some
aspect of a service.

21. DEFINITION
Reports may refer to specific events,
occurrence, or subject and may be
communicated or presented in oral or
written form
[ Basvanthappa BT2009 ]
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22. 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 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.

23. CRITERIA FOR A GOOD
REPORT
• made promptly.
• clear, concise, and complete.
• All important data to be included-the date and
time, the people concerned, the situation, the
signature of the person making the report.

24. CRITERIA FOR A GOOD
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.

25. TYPES OF REPORTS
• Oral report
• Written report
1. 24 hours report
2. Census report
3. Birth and death report
4. Incidental report
5. change – of – shift report
6. transfer report
7. legal report

26. ORAL REPORTS
• Summary of event, observation or
situation by word of mouth is called
oral reporting.
An oral report is simple and easy way
to present .
• It may communicate an impression or
an observation .

27. ADVANTAGE AND DISADVANTAGE OF
ORAL REPORT
• immediate feedback is possible
• Do not add to the permanent records of the
organization.
• needs to comprehend quickly as and when these are
presented.
• May be encumbered with irrelevant facts and
overlook important ones.
• Cannot be referred to again and again
• Have less Professional value.

28. WRITTEN REPORTS
• A written document describing the
findings of some events or
observation is called written reports
• written reports are always preferred
as they enjoy several advantages over
the oral ones.

29. ADVANTAGE AND DISADVANTAGE OF
WRITTEN REPORT
• immediate feedback is not possible.
• Contribute to the permanent records of the
organization.
• can ponder over these reports and understand its
own pace.
• Are more accurate and precise as the writer will
be careful in putting down the facts in writing.
• Can be edited ,reviewed , stored and retrieved.
• Have more professional value.

30. NURSES RESPONSIBILITY IN RECORD
KEEPING AND REPORTING
 It is the responsibility of nurse to make sure records
and reports to be accurate, complete, current ,
organized and make confidential.

31. • Keep under safe custody.
• No individual sheet should be separated.
• Not accessible to patients and visitors.
• Strangers is not permitted to read records.
• Handed carefully, not destroyed.
NURSES RESPONSIBILITY IN RECORD
KEEPING AND REPORTING

32. Nurses should make sure that record and report
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 accurately dated, timed and signed, with the
signature printed alongside the first entry

33. cont..
be written in such a way that any alterations or
additions are dated, timed and signed, so that the
original entry is still clear
not include abbreviations, meaningless phrases,
irrelevant and offensive statements
• Never sent outside of the hospital without the
written administrative permission.