MAINTANENCE OF RECORDS AND REPORTS

Records and reports are the essential components of implementation and evaluation of community health activities. It is necessary for the community health nurse to have thorough knowledge of their maintenance.

RESPONSIBILITIES OF COMMUNITY HEALTH NURSE

Filling of Records

Records can be kept in many ways. It is essential to have proper and systematic filing of records. Properly filed records save time effort. Filing of records depends upon the objective and method adopted by the health agency or enterprise. Some major methods of filing the records are:

1. Alphabetically,2. Numerically, and3. Geographically

Other than these, some health organization file their records using general and specific or divisional method or by using the above mentioned techniques jointly.

1. Records should be clear appropriate and readable.2. Records should be real and based on facts.3. Abbreviations and short form can be used in records, but these short forms should be

generally acceptable and standard.4. Sentence used in records, should be short and clear.5. Paying special attention to numbers and statistics, is essential.6. It is necessary that the person filing the records should sign record with time and date.

Filling of Report

Report like record, should be filed in such a manner that community health nurse gets the correct and timely report.

Report can mainly be filed on the following basis:

1. Place: Report can be filed on the basis of group of houses, lane or villages.2. Time: This can be prepared as the time of completion of work; means report can be

prepared on the daily, monthly, quarterly or annual basis.

3. Alphabet: This can be filed a according to the name of those who started the work or the first letter of activity.

4. Number: Report can be expressed or filed according to numbers or in serial order, like Report No. 1, 3, 3, 4, ……. etc.

Guidelines for Reporting

1. A general method or outline of writing the report should be prepared before actually writing report.

2. As far as possible, printed forms should be used for writing the report.3. It is necessary to collect all information and material to make the report complete.4. Style of report writing should make it easy to understand.5. Report should be arranged in such a manner that essential information can be retrieved

easily.6. Important information should be underlined or expressed in a specific manner.7. Presentation of report should be attractive and the important points should be stressed.8. Report should be comprehensive, factual and based on supervision and actual

information.9. Wording/vocabulary of report should be simple.

Precautions

Community health nurse should take following precautions in the maintenance of reports and records:

1. These should be kept carefully at a clean place.2. These should be protected against mice, termites and insects etc3. Good filing system should be developed for the records and reports.4. These should be easily available on time.5. Confidential record and report should be shown to authorized persons only.6. These should be kept only at the definite place.

Some important Health Records

Given below is the description of some important health records related to community health.

1. Daily Diary

Daily diary is used to note the daily activities of community health nurse. Since, it is not possible to carry all the registers and forms etc. at the time of meeting or supervision, so later on appropriate records can be prepared, on the basis of the entries made in the diary. Daily diary is a notebook (diary), which the nurse should always carry with her, while on duty. Information recorded in the diary should be clean and true.

2. Village Record

Village records provide basic information for health services. Following facts should be included in the village record:

Name of the village, distance of village from health centre. Total number of families and houses in the village/population of village. Religious beliefs of villagers. Number of women in the village in different age groups (0-1, 1-5, 5-15, 15-44) and

married and unmarried women. Number of eligible couples. Number of sais (trained/untrained) in the village. Name and number of depot holders. Information about community health institutions, anganwadis, balwadis, co-operative

institutes and village clubs etc. working in the village. A list of schools, post office, police station, panchayat, places of worship or prayer and

their addresses. Condition of the means of transport and communication. Immunization status of villagers. Actual condition of environmental cleanliness in the village. Description of non-allopathic medical institutions of the village.

3. Cumulative Record

Cumulative means gradually increasing in amount by one addition after another. Hence, cumulative record is a continuing record procedure. Cumulative record is time saving, economical and it is helpful to review the total history of an individual. It evaluates the progress of a long period. Maternal record, nursing student’s clinical record etc. are the examples of cumulative record.

4. Family Folder

Community health nurse has a direct and important role to play in the family health services. Family folder provides a basis for this. Hence it is essential to have following information in the family folder:

Condition and address of the residence of the family. Name of the head of the family. Religion and caste of the family. Names of family members, with their relation, in order of their age. Condition of education and employment/unemployment of each member of family. Economic level of the family. Nutrition and diet of the each member of the family.

Contraceptive used by the couple (if any). If any member of the family is infected with any communicable diseases, present

condition and desctiption of the treatment taken. Condition of environment: This should essentially include the information about type of

house, building material used, light and ventilation arrangement, water supply, sewage, waste disposal, kitchen and condition of bathroom and toilet.