SEMINAR ON

RECORDS AND REPORTS

Presented By:Hemlata

4th Year B.Sc. Nursing.

Introduction

Records • Definition

• Importance

• Principles In Record Writing

• Value $ Uses Of Records

• Types Of Records

• Filling Of Records

Reports

purpose Elements Importance

A record is that which is written

To perpetuate a knowledge ofevents.

OR

A record is a permanent writtencommunication that documentsinformation relevant to aclient’s health caremanagement.

Serves as guidelines

Means of communication

Save efforts and money

Useful in research

Providing continuity of service

Avoid duplication

Evaluation of health services

Act as instrument

for health education

Planning purposes

More than recalling

memory

Principles In record writing

Clarity and legibility

Facts based

Complete and accurate

Continuity in records

Confidential

Written immediately after providing services

Brief information

Develop own method of writing

U s e s O f R e c o r d s

For health personnel

For c l ientFor health agent

-for health

worker

-for nurse

-for doctor

For the Nurse :

Record provides basic facts of her services done for the family or patient

It provide the services done

It provide basis for planning the intervention

It prevents duplication of services and helps follow up services effectively

It helps the nurse to organize her work and save times

For the Doctor :

Records serve as guide for diagnosis, treatment, follow up and evaluation of services.

Indicates progress & continuity of care

Help self- evaluation of medical practice

Protects in case of legal issues

May be used for teaching and research.

For health workers at village

Record will help to know about the details of pregnant women, making use of antenatal services such as registration history, examination and the future plan for delivery and condition of fetus etc.

The MCH, provides the details of delivery conducted

The BIRTH AND DEATH register provides the number of birth and deaths in a day, month and year and causes of death.

REFERAL register provides information about referred cases

CHILD CARE register provides information about immunization date of birth , age, sex, place of birth and birth weight

GROWTH CHART provides weight taken, grading of malnutrition ,height and sickness etc

For the Individual & Family

Records help the individual and family to become aware of their health needs.

Health records or flash card or posters or charts can be used as a teaching tool too.

Health records or any investigation done in any other institutions will be helpful for an effective diagnosis and treatment

For the health agency:

Records help the administration in assessing the performance of their own institute and the needs of the society.

Records provides a justification for expenditure of funds

Record helps in making studies for research for legislation action and for planning budget

Records are the evidence of the services rendered by each worker

Records help the health professionals to evaluate their services rendered, teaching done and a people’s action and reaction

Planned re cord are utilized as a an evaluation tool during conference and meeting

TYPES OF RECORDS

Cumulativerecords

Family records

Anecdotal records

Clinicalrecords

Cumulative or continuing It is economical and time saving.By using and continuing keeping of

cumulative records it is possible to review the total history of an individual and evaluate the progress over a long period.

Family records Separate records forms may be needed for different types

of services such as TB, maternity ,infant and preschool and school and industrial . One family may be making use of any one or all of the time of each visit , in order to describe symptoms, report observation, record the services rendered ,make suggestion on further follow up visit and refer the patient for help or consultation to another worker

Anecdotal records

A factual record of an observation .It is a record of an incident which is considered to be imp and significant in the growth and development of students.

Clinical records

It is knowledge of event in patients illness and progress to recovery and care by the hospital personnel . Information are recorded by doctors, nurses and paramedical staff.

Records In the Hospital

Nominal register

Nurse’s register

Stock register

Duty register

Leave register

Indent register for supplies

Linen register

Records In the Hospital

Census register

Diet register

Paying patient register

Memo book

Death/ mortuary register

Condemnation register

Prescription register

Records in AZARA PHC

Nirodh register

Oral pill register

MCH register

Immunization master

Birth/death register

Eligible couple r register

IUCD 380 A register

Stock register Birth and death register Family register Referral register School health register Eligible couple registerAntenatal cases registerOPD register

Token registerNominal register for in – patientsDeath and Birth register Surveillance register Inspection registerMorbidity register

Having matter order from the physician for treatment and care of the patient .Registration of birth , death and still births are the important vital signs. Medicine should be administered as per the order of physician and also under supervision.

Confidentially in record working and maintenance.

CONT…

Laboratory Information Systems (LIS)

Radiology Information Systems (RIS)

Pharmacy Information Systems (PIS)

Computerized Physician Order Entry (CPOE)

Decision Support Systems (DSS)

Other EMR systems and applications.

CONCLUSION