INTRODUCTION All documents information , regardless its characteristics, media, physical form and the manner it is recorded or stored. Records function as evidence of activities. Express or presenting facts, data, figures or other information in writing is called records means written inf. Of information.
RECORDS . Health records refers to the forms on which information about an individual or family is recorded
REPORTS these are account or statement describing indetail an event, situation, or like, usually as the result of observation, inquiry, etc. a formal or official presentation of facts .
TYPES OF RECORDS1.) PERIODICAL:A.) Permanent records (cumulative)B.) Temporary records(casual/daily records)
CONT….2.) UNIT BASED RECORDS:a.) individual(individual health cards)b.) related to family(family folders)c.) related to community(community folders)d.) National(national health programms records)
Cont….3.) SUBJECT BASED:a.) economical(financial structure of family, villageb.) social(records of social structurec.)Politicald.)Medical and nursing (treatment and medicine recods))
Cont….4.) COLLECTION PLACE BASED:a.) Collected at institutions(records of hospitals/ ealth centersb) Records to be kept with the individual(immunization cards, disease cards)
Records related to community2 categories: A.) Records to be kept under health centers B.)Records to be kept with the patient
Records to be kept under health centers1) family folders MCH cards Antenatal card/ postnatal cards Infant card Pre-school child card Medicine distribution card include records of iron and folic acid distribution cards Family welfare records: eligible couple, mtp, family planning.
Cont……. Treatment and referral records Vital event records: birth and death records General information records; individual records, family, village, map of community Other records:- antenatal records- Medicine records- Monthly/ yearly records- Consumable stock register
Cont……. Stationary stock register Daily diary, cumulative records
To be kept with the PatientKept under supervision of community health nurse: These are:- health record of school going children- infant health card- maternal card- tb patient card- individual health card- Birth and death record- Inpatient and outpatient record
Cont… Eligible couple records Movement register Medicine stock register
IMPORTANT HEALTH RECORDS1.) Daily diary: daily activities of community health nurse2.) Village record: it consist ofName of village,distance from health centerTotal no of familiesTotal populationReligious beliefsNo. of women under different age group
Cont…. No of trained dais No of eligible couples Community health institutions anganwari etc Schools, post offices, police stations, place of worship Means of transportation and communication Environment conditions
Cummulative records Cumulative means gradual increasing in amount by one adding after another It is continuing record procedure Time saving, economical, review total history of individual Evaluate progress for longer peroid (nursing students clinical record)
Family folder Condition and address of residence Name of head of family Religion and cast Name of family member Education, occupation, economic status, diet, eligible couple, environment.
REPORTS Account or statement describing in detail an event, situation or like usually as the result of observation, inquiry etc.
Cont….. A formal or official presentation of facts Reports means fact findings Reports can be oral or written. Can be daily, monthly, quarterly, half yearly and annual. Analytical aspect of a subject or services is presented in a report.
TYPES OF REPORTS 2 TYPES: 1.) Verbal report 2.) Written reportIn hospital important reports are;24hrs reportsNight and day report
Cont…. Supervision report Patient census report Accident report IN COMMUNITY: Anecdotal reports Monthly, quaterly, yearly or annually reports Evaluatory report
IMPORTANCE OF RECORDS AND REPORTS; Assess health level of community. Helps in collecting data. Assessment and evaluation of work. Basis for formulating plans Tool or medium for health education. Determine needs of resources. Legal documentation Means of communication Provide information of good nursing Conduct training and research work Assess health problems.
MAINTANENCE OF RECORDS AND REPORTS Filling of records: Alphabetically, numerically and geographically.GUIDELINES: Clear, appropriate and readable. Real or based on facts. Abbribations and short forms should be of standard. Sentences should be short and clear. Signature of person filled records.
PRECAUTIONS 1.) Kept carefully. 2.) Protected against termites and insects. 3.) Good filling system 4.) Easily available on time. 5.) Kept at definite place. 6.) Confidential