Community Health Nursing IRecords and reports By, Thiru murugan Community health nursing – I (1st GNM) Unit – VIII: Records and reports Types and uses Essential requirements of records and reports. Preparation & Maintenance. RECORD: A record is a clinical, scientific, administrative and legal document relating to the nursing care given to the individual family or community. REPORTS: Reports are oral or written exchanges of information shared between caregivers or workers in a number of ways Reports can be compiled daily, weekly, monthly, quarterly and annually. Report summarizes the services of the nurse and/or the agency. TYPES OF RECORDS Periodical Unit Based Subject Based Collection Placed Based TYPES OF RECORDS 1. Periodical: Permanent Records (Cumulative) Temporary Records (casual/daily records) 2. Unit Based: Individual (individual health cards) Related to family (family folders) Related to community (community folders) 3. Subject Based: Economical (financial structure of family, village) Social (records of social structure) Political Medical and nursing (treatment and medicine records) 4. Collection Placed Based: Collected at institution (records of hospital/ health centers) Records to be kept within individual (immunization cards, disease cards) Nurses responsibility for record keeping and reporting: The patient has a right to inspect and copy the record after being discharged Failure to record significant patient information on the medical record makes a nurse guilty of negligence. Medical record must be accurate to provide a sound basis for care planning. Errors in nursing charting must be corrected promptly in a manner that leaves no doubts about the facts. In reporting information about criminal acts obtained during patient care, the nurse must reveal such information only to the police, because it is considered a privileged communication. Keep under safe custody of nurses No individual sheet should be separated Not accessible to others until necessary Strangers are not permitted to read records Records are not handed over the legal advisors without written permission of the administration Handed carefully, not destroyed Identified with bio-data of the patients such as the name, age, admission number, diagnosis, etc. (Legal issues) Never sent outside of the hospital without the written administrative permission.

1. Community Health Nursing I
Records and reports
By,
Thiru murugan

2. • Community health nursing – I (1st GNM)
• Unit – VIII: Records and reports
a) Types and uses
b) Essential requirements of records and
reports.
c) Preparation & Maintenance.

3. • RECORD:
• A record is a clinical, scientific, administrative and legal document relating to the
nursing care given to the individual family or community.
• REPORTS:
• Reports are oral or written exchanges of information shared between caregivers or
workers in a number of ways
• Reports can be compiled daily, weekly, monthly, quarterly and annually.
• Report summarizes the services of the nurse and/or the agency.
• TYPES OF RECORDS
1. Periodical
2. Unit Based
3. Subject Based
4. Collection Placed Based

4. •TYPES OF RECORDS
1. Periodical:
A.Permanent Records (Cumulative)
B.Temporary Records (casual/daily records)
2. Unit Based:
A.Individual (individual health cards)
B.Related to family (family folders)
C.Related to community (community folders)

5. 3. Subject Based:
A.Economical (financial structure of family, village)
B.Social (records of social structure)
C.Political
D.Medical and nursing (treatment and medicine records)
4. Collection Placed Based:
A. Collected at institution (records of hospital/ health centers)
B. Records to be kept within individual (immunization cards,
disease cards)

6. • Records related to community health nursing
i. Records to be kept at health centres.
ii. Records to be kept with the patients / individuals.
• Records to be kept at health centres.
 Family folder: complete family details
 MCH card: health of mother & child
 Medicine distribution cards: distribution of iron and folic acid tablets, vitamin A solution
and other medicines.
 Family welfare records: 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.
 General information records: This includes records of individual, family, village and
community maps, facts, pictures and health information.
 Other records and reports: sub centre records, primary or health centre records and of
district or teaching hospitals records.

7. • Records to be kept with the patients / individuals.
Though most of the records are prepared by the nurse or under her guidance and
are kept at the health centre, but it is more useful to keep some records with the
patients. Generally, following records are kept with the patients
 Health record of school going child.
 Infant health card (it includes immunization card).
 Maternal card
 TB patient card
 Individual health card

13. Reports

16. • Essential requirements of records and report:
• Fact: real and truthful information should be recorded and reported.
• Accuracy: a client record must be reliable. Information must be accurate so
that health team members have confidence in it.
• Completeness: the information within a recorded entry or a report should be
complete, containing concise and thorough information about a client care
• Currentness: delays in recording or reporting can result in serious omissions
and untimely delays for medical care or a late entry in a chart may causes
legal issues.
• Organization: record must be organized in proper way so that everyone can
access and understand easily.
• Confidentiality: nurses are legally and ethically obligated to keen information
about client’s illnesses and treatments confidential.

23. • Nurses responsibility for record keeping and reporting:
• The patient has a right to inspect and copy the record after being
discharged
• Failure to record significant patient information on the medical
record makes a nurse guilty of negligence.
• Medical record must be accurate to provide a sound basis for care
planning.
• Errors in nursing charting must be corrected promptly in a manner
that leaves no doubts about the facts.
• In reporting information about criminal acts obtained during
patient care, the nurse must reveal such information only to the
police, because it is considered a privileged communication.

24. • Keep under safe custody of nurses
• No individual sheet should be separated
• Not accessible to others until necessary
• Strangers are not permitted to read records
• Records are not handed over the legal advisors without written permission of
the administration
• Handed carefully, not destroyed
• Identified with bio-data of the patients such as the name, age, admission
number, diagnosis, etc. (Legal issues)
• Never sent outside of the hospital without the written administrative
permission.