RECORDS

INTRODUCTION
An effective health record shows the extent of the health problems’ needs and other factors that affect
individuals their ability to provide care and what the family believes. What has been done and what to be done
now also can be shown in the records. It also indicates the plans for future visits in order to help the family
member to meet the needs.

DEFINITION
It is a written communication that permanently documents information relevant to client health care
management. It is a continuing account of the client’s health care needs.

PURPOSES OF RECORDS
 Provides staff member, administrator, or any other members and not only members of the health team
with documentation of the services that have been rendered and supply data that are essential for
programme planning and evaluation.
 To provide the practitioner with data required for the application of professional services for the
improvement of family’s health.
 Records are tools of communication between health workers, the family, and other development
personnel.
 Effective health records show the health problem in the family and other factors that affect health. Thus,
it is more than a standardized sheet or a form.
 A record indicates plans for future.
 It provides baseline data to estimate the long-term changes related to services.
In short we can say the purposes are:
# Communication
# Aids to diagnosis
# Education
# Assessment
# Documentation of continuity, and justification of case
# Research
#Auditing
 # Legal documentation
# Individual case study

PRINCIPLES OF RECORD WRITING

Nurses should develop their own method of expression and form in record writing.
 Records should be written clearly, appropriately and legibly.
 Records should contain facts based on observation, conversation and action.
 Select relevant facts and the recording should be neat, complete and uniform
 Records are valuable legal documents and so it should be handled carefully, and accounted for.
 Records systems are essential for efficiency and uniformity of services.
 Records should provide for periodic summary to determine progress and to make future plans.
 Records should be written immediately after an interview.
 Records are confidential documents.

VALUES AND USES OF RECORDS

1) For a nurse
 Record provides basic facts for services. Records show the health condition as it is and as the patient and
family accepts it.
 Provides a basis for analyzing needs in terms of what has been done, what is being done, what is to be
done and the goals towards which means are to be directed.
 Provides a basis for short and long term planning.
 It prevents duplication of services and helps follow up services effectively.
 Helps the nurse to evaluate the care and the teaching which she has given.
 It helps the nurse organize her work in an orderly way and to make an effective use of time.
 It serves as a guide to professional growth.
 It enables the nurse to judge the quality and quantity of work done.
2) For the family and individual
 Records help them to become aware of and to recognize their health needs. A Record can be used as a
teaching tool too.
3) For the doctor
 Record serves as a guide for diagnosis, treatment and evaluation of services.
 It indicates progress
 It may be used in research
4) For the sanitarian
 The record helps identify families needing service and those prepared to accept help.
 It enables him to draw the nurse’s attention towards any pertinent observation he has made.
5) For the organization and community
 The record helps the supervisor evaluate the services rendered, teaching done and a person’s actins and
reactions.
 It helps in the guidance of staff and students – when planned records are utilized as an evaluation tool
during conferences.
 It helps the administrator assess the health assets and needs of the village or area.
 It helps in making studies for research, for legislative action and for planning budget.
 It is legal evidence of the services rendered by each worker.
 It provides a justification for expenditure of funds

TYPES OF RECORDS
1) Cumulative or continuing records
This is found to be time saving, economical and also it is helpful to review the total
history of an individual and evaluate the progress of a long period. (e.g) child’s record should
provide space for newborn, infant and preschool data.
The system of using one record for home and clinic services in which home visits are
recorded in blue and clinic visit in red ink helps coordinate the services and saves the time.
2) Family records
The basic unit of service is the family. All records, which relate to members of
family, should be placed in a single family folder. This gives the picture of the total services and
helps to give effective, economic service to the family as a whole.
Separate record forms may be needed for different types of service such as TB, maternity
etc. all such individual records which relate to members of one family should be placed in a single
family folder.
 3) Registers
It provides indication of the total volume of service and type of cases seen. Clerical
assistance may be needed for this. Registers can be of varied types such as immunization register,
clinic attendance register, family planning register, birth register and death register.

GUIDE TO SECURE INFORMATION

Recording requires all the basic skills of nursing itself, such as communication, listening,
observation and analysis. The community health nurse and family should sit together and
 Explore the problems, assuring privacy while securing information.
 Not to force information
 Ask questions in a friendly, definite and direct manner, e.g about diet, vaccination
 After every visit, make relevant notes of visit. Community health nurse should discipline herself in her
record writing.
 The nurse needs to have pleasant expression while securing information.
 At one visit required information cannot be obtained and so the community health nurse needs to pay
frequent visits to obtain the necessary data from the family.

FILLING OF RECORDS
Different systems may be adopted depending on the purposes of the records and on the merits of a
system. The records could be arranged
 Alphabetically
 Numerically
 Geographically and
 With index cards

REPORTS
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. These are based on records and registers and so it is relevant for the nurses to maintain the
records regarding their daily case load, service load and activities. Thus the data can be obtained continuously
and for a long period.
DEFINITION
It is oral or written information about a patient by one member of the health team to other.
The criteria for good report should include:
- Promptness
- completeness
- consciousness
- clarity
- organization and accuracy

PURPOSES OF WRITING REPORTS

 To show the kind and quantity of service rendered over to a specific period.
 To show the progress in reaching goals.
 As an aid in studying health conditions.
 As an aid in planning.
 To interpret the services to the public and to other interested agencies.
In addition to the statistical reports, the nurse should write a narrative report every month which provides as
opportunity to present problems for administrative considerations.
Maintaining records is time consuming, but they are of definite importance today in the community health
practice in solving its health problems.

TYPES OF REPORTS
Reports are mainly classified as oral or written
1) Oral reports
Oral reports are given when information is required for immediate cause. Different
types of oral report are:
a) Reports between head nurse and her assistant
b) Reports of the nurse in charge to the physician
c) Reports of the head nurse to the administrative supervisor
2) Written reports
Reports are written when the information is to be used by several people or is more or
less of permanent value. A written report should show an awareness of the time and thinking. It
 should concentrate on the past, present and future state of the patient or the event. It helps in further
planning, decision making, for research and legal purposes. Different types are:
a) day, evening and night reports
b) accident report
c) 24 hour report

CHARACTERISTICS OF GOOD REPORTING AND RECORDING

 accuracy
 conciseness
 thoroughness
 up-to-date
 organization
 confidentiality
 objectivity

INFLUENCE OF RECORDS AND REPORTS ON MANAGEMENT, INFORMATION AND

EVALUATION SYSTEM

1) Registration of births, deaths and still births are very important vital events.
2) Records and reports are good source of statistics.
3) Informed consent is essential before surgery or investigation of patient.
4) Reporting of accidents errors and incompetent behaviours help to manage the situation properly.
5) A lot of information about diseases prevalent in a community may be obtained from hospitals and
health care records.
6) Proper maintance of records and report help in the time of auditing.

CONCLUSION
Records and reports revels the essential aspects of service in such logical order so that the
new staff may be able to maintain continuity of service to individuals, families and communities.