COMMUNITY HEALTH NURSING

CHAPTER- 8 RECORDS AND REPORT

HEMIN JOHNSON

BANGALORE GROUP OF INSTITUTION

INTRODUCTION OF RECORDS AND REPORTS

• Reports are written when the information is to be used by several people or less of permanent value.

• A written report should show an awareness of time and thinking.

• It should concentrate on the past ,present, and future state of patient or family or the event .

• The records and reports should be clear, observation of person’s relationship and events which are needed to write a meaningful report.

• In a community health service, the community health nurse or health worker is responsible for keeping both administrative and service records about community.

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, records and reports are interrelated ,also they are essential and important component of community health, management and nursing.

Records

Definition Records are written formal and legal individual

family and community. It may provide information about personal ,socioeconomic,

psychological environmental and health.

PURPOSE OF RECORDS

o Records are an important tool in controlling and assessing

work; they are kept to help the supervisor .

o Records are written information in notebooks or in

folders designed for their purposes. They may also be kept

or be computerized.

o Assess progress towards goals.

o Make effective decisions.

o Learn what is taking place .

o Provide an insight for re planning purposes.

PRINCIPLES OF RECORDING

Records should be written clearly, accurately,

appropriately .

Nurses should develop their own method of expression

and form in record writing.

Records are confidential document, so it should be

handled carefully.

Care must be taken not to make any errors on the records

if anything is crossed out ,it should be dated and initiated.

Records should be written immediately after an

interview.

Records should be written in chronological order

according to date and time. When recording

medications and treatments, note exact time and date on

which they are carried out.

Records system is essential for efficiency and

uniformity of services.

Record should provide for periodic summary to

determine progress and to make future plans.

Select relevant facts and the recording should be brief

and accurate.

TYPES OF RECORDS

Family records

Cumulative or continuing

records.

Anecdotal records

Clinical records

Other records

Nurses sheet

Doctor order sheet

1) CUMULATIVE OR CONTINUING RECORDS.

By using this records it is possible to review the total history of an

individual and evaluate the progress. This system utilizes one record for home

and clinic services, in which home visits are recorded in red ink and clinic

visit in blue ink helps to coordinate the service and save the time

2) FAMILY RECORDS

All the records which relate to members of one family should be placed in

the single family folder . In this way ,the doctor and the health workers can see

the total situation and give effective economical service to the family as a

whole. The family folder contains all the individual records of one family.

3 ) CLINICAL RECORDS

It is used in the hospital investigations, special treatments and procedures are

written and signed. It is the knowledge of events in patients illness and

progress to recovery and care by the hospital personnel.

4 ) DOCTOR ORDER SHEET

Doctor orders regarding medications , investigations, special treatments, and

procedures are written and signed.

5) NURSES SHEET

Nurses note are record of treatments and nursing measures carried out by the

nurses , their effects, the observations made on the patient.

6) OTHER RECORDS

Lab report sheet ,diet sheets, TPR chart, intake-output chart, special treatment

sheets etc..

7) ANECDOTAL RECORDS

Anecdotal records can be defined as a brief description of an observed

behavior that appears significant for evaluation purposes , done by the

community health nurse during home visit. It provides information about one

particular incident.

Provide snapshots of actual behavior in natural situations that are

significant indicator of total behavior.

They should contain a factual descriptions of what happened ,when

happened ,under what circumstances the behavior occurred.

Each anecdotal record should contain a record of a single incident.

it can be time consuming .