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
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