Records and reports
a) Types and uses
b) Essential requirements of records
and reports
c) Preparation & Maintenance
Introduction:
Record and report are interdependent.
A report can be prepared based on the records.
Similarly, a report can be presented as a record.
A record is always in writing while a report can also be oral.
A report, especially an oral report, can be forgotten while records can be preserved for a long time.
Although literally different, record and report are synonymous and interrelated, being an essential and important component of community health, management and nursing.
So
define record and report:
A “written presentation of information” is a record.
A health record is a form of information collected from an individual, family and community.
A report is also an effective means of communication.
A thorough understanding of the various aspects of community health nursing is essential for proper reporting.
Mainly the reports can be daily, monthly, quarterly, half yearly and so on.
To enlist the various types of records and reports :
political
Medical and Nursing (treatment, medication record)
Collection place based:
Collected in Institutions (Hospital/Health Center Records)
Records maintained by the individual (Immunization Card, Disease Card)
Here, it is important to clarify that any type of record is not limited or complete and it may be desirable to adopt a view of desirable adaptation in this regard because just as family records can be social, so social records are community and national health records. May be based on
Types of repots:
A complete and detailed report plays an important role in health management.
Mainly, there are two types of reports:
verbal report
written report
24-hour report, day and night report, supervisor’s report, patient census report and accident report etc. are major reports in the field of institutional or hospital nursing.
While the field of community health nursing includes birth and death report, anecdotal report and monthly, quarterly, half yearly and annual report of progress and evaluation of health work.
to discuss various types of records to be kept at community health center:
Keeping records at health centres: (reports to be kept at health centre)
family folder:
This includes the family, its constituents, structure, and individual cards.
Maternal and Child Health Card:
This can be part of the family folder.
It includes antenatal card/postnatal card immunization card
Infant Card
Pre-school child cards
Drug Dispensing Card:
This includes the dispensing records of iron and folic acid tablets, vitamin A solution and other medicines
Family welfare records:
This includes eligible couple records, family planning records, MTP records and other related records.
Treatment and Referral Records:
This includes records related to treatment of health problems, treatment of patients, home nursing, home visiting and referral system.
Record of Vital Events: It includes information and registration of birth and death records.
General information record: This includes individual, family, village and community maps, facts, pictures and health information.
Other records and reports:
Attendance Register
Medicine stock register
Meeting records
Monthly/annual records
Movement register
Stationery Stock Register
Patient registration record (outdoor, indoor registration according to category of health institution)
Register of Depot Holders
to discuss important health records related to community health:
Some important health records:
Similar important health records related to community health are described below.
Daily diary:
A daily diary is used to record the daily activities of a community health nurse.
As it is not possible to carry all the resisters and forms etc. at the time of meeting or supervision, a suitable record can be prepared later based on the entries made in the diary.
A daily diary is a notebook (diary) that a nurse should always carry with them while on duty.
The information recorded in Dairy should be clean and correct.
Village record:
Village records provide a basis for information on health services.
The following facts should be included in the village record:
village name,
Distance of village from health center
Total number of families and households in village/village population.
Religious Beliefs of the Villagers.
Number of women in different age groups (0-1,1-5,
5-15,15-44)
and married and unmarried women.
Number of eligible couples.
Number of ASHAs, and dais (trained/untrained) in the village.
Name and number of Depot holder.
Community health institutes, Anganwadis, Kindergartens,
Co-operative Institutions and Village Clubs Operative Institutes and
Information about Gram Club etc.
List of schools, post offices, police stations, panchayats, places of worship
or prayers and their addresses.
Condition of transport and means of communication.
Immunization status of villagers.
Actual status of environmental sanitation in the village.
Description of Village Non-Allopathic Medical Institutions.
cumulative record:
Cumulative record
Cumulative means gradually
Increasing the amount by one-by-one addition. Therefore, a cumulative record is a continuous record process.
Cumulative records save time and are helpful in reviewing a person’s total history.
It assesses long-term progress.
માતાનો રેકોર્ડ, નર્સિંગ વિદ્યાર્થીનો ક્લિનિકલ રેકોર્ડ વગેરે..એ સંચિત રેકોર્ડના ઉદાહરણો છે.
family folder:
કુટુંબ ફોલ્ડર:
કૌટુંબિક આરોગ્ય સેવાઓમાં community health nurse એ સીધી અને મહત્વપૂર્ણ ભૂમિકા છે.
કૌટુંબિક ફોલ્ડર આ માટે એક આધાર પૂરો પાડે છે.
આથી ફેમિલી ફોલ્ડરમાં નીચેની માહિતી હોવી જરૂરી છે:
પરિવારના રહેઠાણની સ્થિતિ અને સરનામું.
કુટુંબના વડાનું નામ.
પરિવારનો ધર્મ અને જાતિ.
પરિવારના સભ્યોના નામ, તેમના સંબંધ સાથે, તેમની ઉંમરના ક્રમમાં.
દરેકની શિક્ષણ અને રોજગાર/બેરોજગારીની સ્થિત
કુટુંબનું આર્થિક સ્તર
કુટુંબના દરેક સભ્યનું પોષણ અને આહાર
દંપતી દ્વારા ઉપયોગમાં લેવાતી ગર્ભનિરોધક (જો કોઈ હોય તો)
જો પરિવારના કોઈપણ સભ્યને ચેપ લાગ્યો હોય
કે કોઈપણ ચેપી રોગો સાથે, હાલની સ્થિતિ અને લેવામાં આવેલી સારવારનું વર્ણન.
પર્યાવરણની સ્થિતિ:
ઘરનો પ્રકાર,
વપરાયેલ મકાન સામગ્રી, પ્રકાશ અને
વેન્ટિલેશનની વ્યવસ્થા,
પાણી પુરવઠો,
ગટર,
કચરાનો નિકાલ,
રસોડું અને
બાથરૂમ અને
શૌચાલયની સ્થિતિ વિશે.
પછી નવીનતમ માહિતી એકત્રિત કરવા માટે
ફેમિલી ફોલ્ડર બનાવવા માં વ્યક્તિગત હેલ્થ કાર્ડ રાખી શકાય, ફેમિલી ફોલોઅપ શીટનો ઉપયોગ કરવો જોઈએ.
To describe uses of records and reports:
રેકોર્ડ્સ અને રિપોર્ટ્સનો ઉપયોગ (uses of records and reports) :
a) રેકોર્ડ્સ અને રિપોર્ટ્સ communityના health levelનું મૂલ્યાંકન કરવામાં મદદ કરે છે.
b) આ health officer અને health institute ને health ની માહિતી એકત્રિત કરવામાં મદદરૂપ થાય છે.
c) આ કામના assessment અને evaluation માં ઉપયોગી છે
D) આરોગ્ય સેવાઓમાં યોજનાઓ ઘડવામાં આધાર પૂરો પાડો છે અને આ ભાવિ યોજનાઓનું પ્રતીક તરીકે ઉપયોગી છે.
e) આ વ્યક્તિગત, કુટુંબ અને સમુદાય માં આરોગ્ય શિક્ષણ પ્રદાન કરવાના tool/માધ્યમ તરીકે કામ કરે છે.
f) સંસાધનોની જરૂરિયાત (દવાઓ, equipment, પુરવઠો વગેરે) નક્કી કરવામાં સહાય કરો.
g) આ community health activity ઓ માટે કાનૂની દસ્તાવેજો પ્રદાન કરે છે.
h) આ continuity અથવા નર્સિંગ સંભાળ માટે માહિતીનો પ્રચાર કરે છે. આ આરોગ્ય કર્મચારીઓ અન…
Essential requirements for records and reports
introduction:
પરિચય:
Facts , ડેટા, આંકડાઓ અને અન્ય માહિતીને લેખિતમાં વ્યક્ત કરવી અથવા રજૂ કરવી તેને રેકોર્ડ રિપોર્ટ કહેવામાં આવે છે તે પણ સંચાર (communication) નું અસરકારક માધ્યમ છે.
યોગ્ય રિપોર્ટિંગ માટે community health નર્સિંગના વિવિધ પાસાઓની સંપૂર્ણ સમજ હોવી જરૂરી છે.
અહેવાલો મૌખિક અથવા લેખિત હોઈ શકે
Define record and report:
રેકોર્ડ એ “માહિતીની લેખિત રજૂઆત (written presentation of information) ” છે.
રેકોર્ડ એ વ્યક્તિ, કુટુંબ અને સમુદાય પાસેથી મેળવેલ માહિતીનું એક સ્વરૂપ છે.
Report એ communication નું અસરકારક માધ્યમ છે.
તે યોગ્ય રિપોર્ટિંગ માટે તેને community health નર્સિંગના વિવિધ પાસાઓની સંપૂર્ણ સમજ હોવી જરૂરી છે.
અહેવાલો મૌખિક અથવા લેખિત હોઈ શકે છે.
Enlist the purpose of records and reports:
રેકોર્ડ અને રિપોર્ટના હેતુની નોંધણી કરો:
Purpose of records:
સ્ટાફ મેમ્બર, એડમિનિસ્ટ્રેટર અથવા અન્ય કોઈપણ સભ્યો અને માત્ર હેલ્થ ટીમના સભ્યોને જ નહીં કે જે સેવાઓ provide કરવામાં આવી છે તેના documnetation અને પ્રોગ્રામ પ્લાનિંગ અને મૂલ્યાંકન માટે record એ જરૂરી ડેટા પૂરા પાડે છે.
પરિવારના સ્વાસ્થ્યના સુધાર માટે record એ health care person ને જરૂરી ડેટા provide કરે છે.
રેકોર્ડ્સ આરોગ્ય કર્મચારીઓ, પરિવાર અને અન્ય વિકાસ કર્મચારીઓ વચ્ચે communication નું સાધન છે.
Effective health રેકોર્ડ કુટુંબમાં health problem અને આરોગ્યને અસર કરતા અન્ય પરિબળો દર્શાવે છે. આમ, તે standardized sheet અથવા ફોર્મ કરતાં વધુ છે.
રેકોર્ડ ભવિષ્ય માટેની યોજનાઓ સૂચવે છે.
તે સેવાઓ સંબંધિત લાંબા ગાળાના ફેરફારોનો અંદાજ કાઢવા માટે આધારરેખા ડેટા પ્રદાન કરે છે.
Purpose of reports:
Useful to show the type and quantity of service provided for a particular period.
Useful for showing progress towards reaching goals.
Useful as an aid in studying health conditions.
Useful as an aid in planning.
Useful for interpreting services to the public and other interested agencies.
Describe essential requirements for records and reports:
Essential Requirements for Records and Reports:
Nurses should develop their own method of expression and form in writing records.
Records should be clearly, properly written
Legibly records should contain facts based on observation, conversation and action.
Select the relevant fact and the recording should be neat, complete and uniform
Records are valuable legal documents and should therefore be handled carefully, and accounted for.
Record systems are essential for the efficiency and uniformity of those services.
Records should provide periodic summaries to determine progress and make future plans.
Records should be written immediately after the interview.
Records are confidential documents.
Discuss legal implications of records and reports:
Legal implications of records and reports:
Legal Implications of Records and Reports:
Records and reports have legal significance of birth and death rights.
Their legal meaning can be explained under three approaches.
Individual approach
Community approach
Nursing approach
Individual approach:
(personal approach)
Birth-death report, individual health card, green card (sterilization certificate), immunization chart, maternal description etc.
All records and reports have legal significance.
Not only in the health sector but in all walks of life individuals get facilities and legal protection based on records.
community approach:
(community approach)
Health records provide confirmation, evaluation and protection of basic rights of citizens related to health.
Records and reports provide the legal basis by which charges can be levied against the medical administration and political system for health problems prevailing in a particular community area, deficiencies in health program implementation, errors in evaluation, and medical and administrative inactivity.
Public lawsuits can also be filed for better implementation of the health program under legal protection and the administration can be held accountable.
Irresponsible people, organizations and enterprises may be punished for non-compliance with health regulations,
To achieve all this, proper recording and maintenance of community health records and reports is essential.
3.Nursing approach:
(Nursing approach)
Maintaining personal and family health records of patients.
Adopting the proper method of filing.
Maintaining confidentiality of records of abortion, MTP, contraceptive use and communicable diseases.
Records should be disclosed only to authorized persons.
In case of consumer protection act or any other court work to produce record in due course, prepare a register for same and protect parent health organization/agency against contempt of court.
To destroy obsolete records, a legally acceptable process must be used.
Records related to medico-legal cases, deaths
Declaration and will etc. should be handled carefully, becoming useful for witnessing whenever needed.
Effective health records show the needs of health problems and other factors that affect the individual’s ability to provide care and what the family believes.
What has been done and what needs to be done can also be shown in the record.
It also suggests plans for future visits to help the family member meet needs.
Record keeping is time consuming, but it has definite importance in community health practice today in solving its health problems.
Define record and report:
A record is a “written presentation of information”.
A record is a form of information obtained from an individual, family and community.
Report is an effective means of communication.
It requires a thorough understanding of various aspects of community health nursing for proper reporting.
Reports can be oral or written.
Discuss the method of maintenance of reports:
Maintenance of records and reports:
(Responsibility of community health nurse:)
Maintenance of Records and Reports (Community Health Nurse Responsibilities):
Records and reports are essential components for implementation and evaluation of community health activities.
Community health nurses need to know their maintenance.
Some important facts regarding record and report filling (entries) and maintenance are given below:
Filling of records:
(filling records)
Records can be kept in many ways.
Proper and systematic filling of records is essential. Proper records save time and effort.
The record keeping basis depends on the objective and method adopted by the health agency or enterprise.
Some of the main methods of filling records are:
Alphabetically
Numerically
(numerically)
Geographically
(geographically)
Apart from this, some health institutions file their records using general and specific or departmental method or using a combination of the above techniques.
Filling the report:
(Filling of Report)
The report, like the record, should be entered in such a way that the community health nurse receives an accurate and timely report.
A report can be filed primarily on the following grounds:
Place: Reports can be filed based on groups of houses, streets or villages.
Time: This can be prepared as the time of completion of the work, ie report can be prepared on daily, monthly, quarterly yearly basis.
Alphabet: This work can be filed according to the name of the initiator or the first letter of the activity.
Numbering: Reports can be expressed or filed according to numbers or in serial order, such as report number 1, 2, 3, 4…etc.
To enumerate guidelines of the records and report:
Guidelines for recording:
(Guidelines for Recording)
Records should be clear, correct and legible
Records should be factual and based on facts.
Abbreviations and short forms may be used in records, but these short forms must be generally acceptable and standard.
The sentence used in the record should be short and clear.
Paying special attention to numbers and figures is essential
The person filing the record must sign the record with time and date.
Guidelines of reporting:
Before actually writing the report, a general method or outline of writing the report should be prepared.
A printed form should be used for writing the report as far as possible.
All information and materials must be collected to complete the report.
The way the report is written should make it easy to understand.
The report should be organized in such a way that the required information can be easily retrieved.
Important information should be clearly expressed and underlined.
The presentation of the report should be attractive and emphasize important points
The report should be comprehensiv, factual and full of oversight and correct information.
The wording of the report should be simple and understandable. to enlist precautions in maintenance of records and reports:
(What precautions will you take to maintain the report)
Precaution:
(precautionary measures)
A community health nurse should take the following precautions in maintaining reports and records:
It should be kept carefully in a clean place.
It should be protected against rats, termites and insects etc.
A good filling system should be developed for records and reports.
These should be readily available on time.
Confidential records and reports should be disclosed only to authorized persons.
It should be kept only in a definite place.