Maintenance of health records for self and family, record and reort

1. Maintenance of health records
for self and family
By,
Mr. Abhishek Verma

2. INTRODUCTION
• Maintaining comprehensive health records for
yourself and your family is essential for effective
healthcare management. These records serve as a
crucial reference point for medical professionals,
aiding in accurate diagnosis, treatment, and
preventive care.

4. RECORDS
Health records refer to the forms on which
information about an individual or family is
recorded.
• Records present facts, data, figures or other
information in writing is called records.
• Records work as an evidence of activities.
• It also indicates the plans for the future visits
in order to help the family member to meet the
needs.

5. Importance:
• Assessing the health of the community.
• Collecting statistics needed for health
authorities.
• Attention of the doctor or other members of the
health team to specific needs of individuals or
families and for follow up services.
• Assessing need for various drugs, transport, etc.
based on numbers and types of patients.
• A tool for health education of individuals,
families and communities.
• Evaluating progress of the health programmes.

6. Principles of records:
• Clearly identify the client by name and
identification number or date of birth on each page
of the record.
• Each side of the page should be numbered.
• Record should be factual, consistent and
accurate.
• Record should be written clearly and legibly in such
a manner that the text cannot be erased.
• Date and time should be mentioned in the record.
• Be signed with the signature printed alongside each
entry, together with professional status.
• Any alterations or additions are dated, timed and
signed.
• Record should be based on subjective statements.

7. Types of records:
• 1. Periodical records
▫ Permanent records (cumulative)
▫ Temporary records (casual / daily)
• 2. Unit based records
▫ Individual health records
▫ Family records (family folders)
▫ Community records (community folders)
▫ National (National Health Programmes records)
• 3. Subject based records
▫ Economical (financial structure of family, village)
▫ Social record (records of social structure)
▫ Political records
▫ Medical and nursing (treatment and medicine records)

8. Cont…
• 4. Family health records
▫ Family folder
▫ Individual health record
▫ Cumulative record
▫ Register

9. Records maintained in sub-centre:
• Village records (general information about
the village)
• Family folder and individual health cards
• Eligible couple register
• Record of contraceptives distributed
• MCH records (antenatal care, child care,
nutrition and immunizations)
• Records of distribution of iron and folic acid
and vitamin A solution
• Vital events register

10. Cont…
• Stock register for receipt, issue and balance of
drugs, contraceptives, stationery, etc.
• Records of medical care and referral
• Inventory of furniture, linen and equipment
• Records of meetings with village health
guides and dais, co-workers and supervisors.
• Monthly reports and other periodic reports as
and when required
• Daily diary
• Maps, charts and graphs.

11. Maintenance of records:
• Record must be kept carefully and in clean
conditions, safe from rats and insects.
• Records should not be lost or misplaced.
• Records are confidential and should be shown
only to authorize persons.
• Maintaining good system of filling
(alphabetically, numerically, geographically and
with index card)
• Records should be divided into localities and
filed in order of house numbers.
• Records should have a register or index cards filled
in alphabetical order of the heads of the families.

12. REPORTS
Reports are oral or written exchanges of
information shared between care givers or
workers in a number of ways.
• A report summarizes the services of the person
or personnel of the agency.
• Reports are usually written daily, weekly,
monthly or yearly.

13. Purposes of reports:
• To show the kind and amount of services
rendered over a specified period.
• To illustrate in reaching goals.
• As an aid in studying health conditions.
• As an aid in planning.
• To interpret the services to the public and to the
other interested agencies.
• They save duplication of efforts and eliminate
the need for investigation to learn the facts in
situation.

14. Types of reports:
• 1. Oral reports: Oral reports are given when
the information is for immediate use and not
for permanency.
▫ Eg., staff nurse to the relieving nurse or
supervisor or doctor.
• 2. Written reports: Reports are to be written
when the information is to be used by several
personnel, which is more or less
permanent value.
▫ Eg., day and night reports, census, etc.

15. Reports at sub centre setting:
• Monthly sub centre reports
• Weekly sub centre reports
• Annual list of eligible and target couples
• List of births or deaths
• Report on the utilization of disposable delivery
kits
• List of malaria slides