RECORDS & REPORTS: DOCUMENTATION

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.

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 shows 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.

 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

• 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.
  

•  Records help them to become aware of and to recognize their health needs. A Record can be used as a teaching tool too.
  

• Record serves as a guide for diagnosis, treatment and evaluation of services.
  
• It indicates progress
  
• It may be used in research
  

• 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.
  

• 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.
  

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
  

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.

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.

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.

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.

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Posted in: Advance Nursing,Nursing Management