Students will be able to understand the knowledge Record and reports

1. RECORDS AND REPORTS
Prepared by:
Mrs. Sujatha

2. Relation of Record and Report
• Record and report are mutually interdependent.
Report can be prepared on the basis of records.
• Similarly, report can be presented as record.
• Record is always in the written form while report
can be oral as well.
• Report especially oral report, can be forgotten while
record can be preserved for a long time.
• Despite being literally different, record and report
are synonymous and interrelated, also they are the
essential and important component of community
health, management and nursing.

3. RECORDS
• Records are the information kept in the health
unit on the work of the unit, on the health
conditions in the community, on individual
patients, as well as information on
administrative, matters: staff, equipment,
supplies, etc.

4. PURPOSE OF RECORDS
• Records are written information in notebooks or
in folders designed for their purposes. They may
also be kept or be computerized.
• Records are the administration’s memory.
• Records are an important tool in controlling and
assessing work; they are kept to help the
supervisor to:
- Learn what is taking place
- Make effective decisions
- Assess progress towards goals
- Provide an insight for re planning purposes

5. Types of records
• Records can be seen in various forms. Records
can mainly be categorized in four ways.
1. Periodically:
• Permanent records ( e.g cumulative records)
• Temporary records (e.g casual or daily records)
2. Unit based:
• Individual (e.g individual health card)
• Related to family (e.g family folder)
• Related to community (e.g records of health
problems).
• National (e.g national health programme record)

6. Continue…..
3. Subject Based :
• Economical (financial structure of family, village)
• Social (records of social structure)
• Political
• Medical and nursing (treatment, medicine record)
4. Collection place based :
• Collected at institutions (records of hospital and
health center)
• Records to be kept with the individual
(immunization card, disease card)

7. RECORDS RELATED TO CHN
The records in community health nursing can be
divided into two categories:
(i) Records to be kept at health centers, and
(ii) Records to be kept with the patients /
individuals.

8. Records at Health Centers
• Family folder: Includes family, its constituent,
structure and individual card.
• Mother and child health card: These can be
part of family folder. They include;
Antenatal card / Postnatal card
Immunization card
Infant card
Pre-school child cards

9. Continue…..
• Medicine distribution cards: This includes
distribution record of iron and folic acid tablets,
vitamin A solution and other medicines.
• Family welfare records: These includes records of
eligible couples, family Planning records, MTP
records and other related records.
• Treatment and referral records: This includes
records related to remedies of health problems,
treatment of patients, home nursing, home visiting,
and referral system.
• Vital events record: These include information and
registration of birth and death records.

10. CONTINUE…….
• General information records: This includes records of
individual, family, village and community maps, facts, pictures
and health information.
• Other records and reports:
• Records kept at health institution can also be categorized as
sub center records, primary or community health center
records and of district or teaching hospitals records.
- Attendance register
- Medicine stock register
- Meeting records
- Monthly / yearly report
- Consumable stock register
- Movement register
- Stationary stock register
-Patient registration record
(outdoor, indoor registration
according to the category of
health institution)
-- Depot holder register
-- Daily diary, cumulative
record and other register

11. Important types of records
• Family folder card
• Individual health record
• FP card
• Antenatal card
• Child health card

12. RECORDS KEPT WITH PATIENTS &
MOTHERS
• Though most of the records are prepared by the community
health nurse or under her guidance and are kept at the health
center, but it is more useful to keep some records with the
patients and mothers.
• Generally, following records are kept with the mothers and
patients.
 Health record of school going child.
 Infant health card (it includes immunization card).
 Maternal card
 TB patient card
 Individual health card

13. REPORTS
• Reports are the information communicated to
the other levels of the health services. They
are also an important management tool to
influence future actions.

14. TYPES OF REPORTS
• The types of the report are
-oral or by telephone or radio in emergency
cases (verbal)
-written in normal circumstances

15. Types of reports
• 24 hour report
• Supervisor’s report and Patient’s census report
• Night and day report and
• Accident report etc. are the main reports in the
field of institutional or hospital nursing, while in
the area of community health nursing
• Birth and death report
• Anecdotal report and the
• monthly, quarterly, half yearly and annual report of
progress and evaluation of health work are also
included.

16. IMPORTANCE OF RECORDS AND REPORTS
(1) Records and reports assist in assessing the health
level of the community.
(2) These provide help for health officers and
institutions in collecting data.
(3) These are useful in the assessment and evaluation
of work.
(4) Provide basis in formulating plans in the health
services. These are the symbol of future plans.
(5) These work as the tool / medium of providing
health education to individual, family and
community.

17. CONTINUE……
(6) Assist in determining the need of resources
(medicines, equipments, supplies etc.)
(7) These provide legal documentation for the
community health activities.
(8) These propagate the information for the
continuity of care and nursing. These are the
means of communication between the health
workers and the community.
(9) These provide information for good nursing.
(10) Without these, it is difficult to conduct
training and research work.

18. CONTINUE….
(11) Record and report are essential for the
evaluation, improvisation and rebuilding of
plans for the health programmes.
(12) They contribute significantly in assessing
the health problems of community.

19. CONTINUE…..
• Records are an important tool in controlling and
assessing work; they are kept to help the supervisor to:
- Learn what is taking place
- Make effective decisions
- Assess progress towards goals
- Provide an insight for replanning purposes
• Records are the administration’s memory.
• Reports are the information communicated to the other
levels of the health services. They are also an important
management tool to influence future actions.

20. LEGAL IMPLICATIONS OF RECORDS&REPORTS
• The legal importance of records and reports
are explained under 3 approaches:
INDIVIDUAL APPROACH
COMMUNITY APPROACH
NURSING APPROACH

21. CONTINUE…..
• INDIVIDUAL APPROACH:
Birth – death report, individual health card, green card
(sterilization certificate), immunization chart, maternal
description etc. all records and reports have legal
importance. Not only in the field of health but in all fields
of life, individuals get facilities and legal protection on
the basis of records.

22. CONTINUE….
• COMMUNITY APPROACH:
- Health records provide confirmation, evaluation and protection of
basic rights of citizens, related to health. Records and reports present
the legal basis through which charges can be levied against medical
administration and political system, for health problems prevalent
in the community, shortcoming in the implementation of health
programmes, mistakes in the evaluation, and medical &
administrative inactivity.
- Public litigation can also be filed and administration can be made
responsible for the better implementation of health programmes
under legal protection.
- Irresponsible people , organizations and enterprises can be punished
for not following the health regulations.
- Proper recording and maintenance of community health records
and reports is essential to achieve all this.

23. CONTINUE…..
• NURSING APPROACH:
- Preserving the individual and family health
records of the patients. Adopting the right
method of filling.
-Maintaining the confidentiality and privacy of
the records of abortion, MTP, use of
contraceptives and communicable diseases.
- Records should be shown to authorized
persons only.

24. CONTINUE….
- Presenting the record at the right time, in case
of consumer protection law or for any other
court work, preparing a register for it and
protecting the parent health organization/
agency against contempt of court.
- For destroying obsolete records, legally
acceptable process should be used.
- Records related to medico-legal cases, dying
declaration and will etc. should be handled
carefully for giving witness, whenever needed.

25. CONTENT OF RECORDS AND REPORTS
• Its content (statistical information on births,
deaths, morbidity or comments on program
developments or difficulties), and its
frequency and utilization will differ from
country to county.

26. USES OF RECORDS AND REPORTS
• In assessing the quality of care and the use of
services that are delivered to clients, community
health agencies rely on the client’s record.
• Records should be accurately accessible and
useful. In other words, they must be truly
available when needed, and contain information
that management uses as a yardstick.

27. USES OF RECORDS AND REPORTS
• In all health work it is important to keep
sufficient records to record is to remember.
• Public health records serve to communicate
information between different health workers.
• Recording is the basis for measuring diseases
and activities.

28. SOAPIER
• SOAPIER - is an acronym used to designate the
recording process, with a notation made for each
of the letters.
S - Subjective data
O - Objective data
A - Assessment
P - Planning
I - Implementing
E - Evaluation
R - Reassessment

29. Essentials of good reporting
• Accurate
• Legible
• Complete
• Short and clear
• Timeliness

30. MAINTENANCE OF RECORDS & REPORTS
• Records & Reports are the essential
components of implementation and
evaluation of community health activities.
Some of the important facts related to the
filling and maintenance of records and reports
are as follows:

31. CONTINUE….
1) Filling of Records: Records can be kept in many ways.
• It is essential to have proper and systematic filling of
records.
• Properly filed records save time and effort.
• Filling of records depends upon the objective and method
adopted by the health agency or enterprise.
Methods of filling the records are:
(I) Alphabetically
(II) Numerically
(III)Geographically

32. GUIDELINES FOR RECORDING
1. Records should be clear, appropriate and readable.
2. Records should be real and based on facts.
3. Abbreviations and short form can be used in
records, but these short forms should be generally
acceptable and standard.
4. Sentence used in records, should be short and
clear.
5. Paying special attention to numbers and statistics,
is essential.
6. It is necessary that the person filing the records
should sign record with time and date.

33. Filling of report
Report can mainly filed on the following basis:
1. Place: Report can be filed on the basis of group of houses,
lane or villages.
2. Time: This can be prepared as the time of completion of
work; means report can be prepared on the daily, monthly,
quarterly or annual basis.
3. Alphabet: This can be filed according to the name of those
who started the work or the first letter of activity.
4. Number: Reports can be expressed or filed according to
numbers or in serial order, like Report No. 1,2,3,4…..etc.

34. GUIDELINES FOR REPORTING
1. A general method or outline of writing the report
should be prepared before actually writing report.
2. As far as possible, printed forms should be used for
writing the report.
3. It is necessary to collect all information and
material to make the report complete.
4. Style of report writing should make it easy to
understand.
5.Report should be arranged in such a manner that
essential information can be retrieved easily.

35. CONTINUE….
6. Important information should be underlined
or expressed in a specific manner.
7. Presentation of report should be attractive
and the important points should be stressed.
8. Report should be comprehensive, factual and
based on supervision and actual information.
9. Wording / vocabulary of report should be
simple.

36. PRECAUTIONS
• The community health nurse should take following
precautions in the maintenance of reports and
records:
1. These should be kept carefully at a clean space.
2. These should be protected against mice, termites and insects
etc.
3. Good filing system should be developed for the records and
reports.
4. These should be easily available on time.
5. Confidential record and report should be shown to
authorized persons only.
6. These should be kept only at the definite place.

37. CONCLUSION
• Record and report are mutually
interdependent. Report can be prepared on
the basis of records. Similarly the report can
be presented as record. Health record is a
form of information procured from the
individual, family and community. On its basis,
doctors and nurses can provide maximum
possible health facilities to individual, family
and community.

38. THANK YOU