Records and Report

1. RECORDSRECORDS
ANDAND
REPORTSREPORTS
Prepared by:
Mr. Kuldeep Vyas
M.Sc. Nursing CHN

2.  Records are the information kept in the health unit on
the work of the unit, on the health conditions in the
community, on individual patients, as well as
information on administrative, matters: staff,
equipment, supplies, etc.

3. DEFINITION:
 Records the memory of the internal and external
transactions of an organization. Records contain a written
evidence of the activities of an organization in the form of
letters, circulars, reports, contracts, invoices, vouchers,
minutes of meeting, books of account etc.
[ S.L.Geol, 2001 ]

4. DEFINITION:
A record is a permanent written communication
that documents information relevant to a client’s
health care management.
-Potter and Perry

5.  Record and report are mutually interdependent. Report can be
prepared on the basis of records.
 Similarly, report can be presented as record.
 Record is always in the written form while report can be oral
as well.
 Especially oral report, can be forgotten while record can be
preserved for a long time.
 Despite being literally different, record and report are
synonymous and interrelated, also they are the essential and
important component of health, management and nursing.

6. • Records are the administration’s memory.
• Records are an important tool in controlling and
assessing work; they are kept to help the supervisor to:
- Learn what is taking place
- Make effective decisions
- Assess progress towards goals
- Provide an insight for re-planning purposes

7.  Records can be seen in various forms. Records can mainly
be categorized in four ways.
1. Periodically:
 Permanent records ( e.g cumulative records)
 Temporary records (e.g casual or daily records)
2. Unit based:
 Individual (e.g individual health card)
 Related to family (e.g family folder)
 Related to Health Sector (e.g records of health problems).
 National (e.g national health programme record)

8. 3. Subject Based :
 Economical (financial structure of family, village)
 Social (records of social structure)
 Political
 Medical and nursing (treatment, medicine record)
4. Collection place based :
 Collected at institutions (records of hospital and health
center)
 Records to be kept with the individual (immunization card,
disease card)

9. The records in nursing can be divided into two
categories:
(i) Records to be kept at health centers.
(ii) Records to be kept with the patients / individuals.

10.  Family folder: Includes family, its constituent, structure
and individual card.
 Mother and child health card: These can be part of
family folder. They include;
 Antenatal card / Postnatal card
 Immunization card
 Infant card
 Pre-school child Health cards

11.  Medicine distribution cards: This includes distribution record
of iron and folic acid tablets, vitamin A solution and other
medicines.
 Family welfare records: These includes records of eligible
couples, family Planning records, MTP records and other
related records.
 Treatment and referral records: This includes records related
to remedies of health problems, treatment of patients, home
nursing, home visiting, and referral system.
 Vital events record: These include information and registration
of birth and death records.

12.  General information records: This includes records of
individual, family, village and community maps, facts,
pictures and health information.
 Other records and reports:
 Records kept at health institution can also be categorized as
 sub center records, primary or health center records and of
district or teaching hospitals records.
- Attendance register
- Medicine stock register
- Meeting records
- Monthly / yearly report
- Consumable stock register
- Movement register
- Stationary stock register
-Patient registration record
(outdoor, indoor registration
according to the category of
health institution)
-- Depot holder register
-- Daily diary, cumulative
record and other register

13. • Family folder card
• Individual health record
• FP card
• Antenatal card
• Child health card

14.  Though most of the records are prepared by the nurse or under
her guidance and are kept at the health center, but it is more
useful to keep some records with the patients and mothers.
 Generally, following records are kept with the mothers and
patients.
 Health record of school going child.
 Infant health card (it includes immunization card).
 Maternal card
 TB patient card
 Individual health card

15.  Reports are the information communicated to the other
levels of the health services. They are also an important
management tool to influence future actions.

16. DEFINITION
A report containing information against in
a narrative graphic or tabular form, prepared on
periodic, receiving, regular or as a required basis.
Reports may refer to specific periods, events,
occurrence, or subject and may be communicated or
presented in oral or written form
[ Basvanthappa bt.2009 ]

17.  The types of the report are
-Oral or by telephone or radio in emergency cases
(verbal)
-Written in normal circumstances

18.  24 hour report
 Supervisor’s report and Patient’s census report
 Night and day report and
 Accident report etc. are the main reports in the field of
institutional or hospital nursing, while in the area of
community health nursing
 Birth and death report
 Anecdotal report and
 monthly, quarterly, half yearly and annual report of progress
and evaluation of health work are also included.

19. (1) Records and reports assist in assessing the health level of the
Patients.
(2) These provide help for health officers and institutions in
collecting Statistical data.
(3) These are useful in the assessment and evaluation of work.
(4) Provide basis in formulating plans in the health services.
These are the symbol of future plans.
(5) These work as the tool / medium of providing health
education to individual, family and community.

20. (6) Assist in determining the need of resources (medicines,
equipments, supplies etc.)
(7) These provide legal documentation for the community
health activities.
(8) These propagate the information for the continuity of
care and nursing. These are the means of communication
between the health workers and the community.
(9) These provide information for good nursing.
(10) Without these, it is difficult to conduct training and
research work.

21. (11) Record and report are essential for the evaluation,
improvisation and rebuilding of plans for the health
programmes.
(12) They contribute significantly in assessing the health
problems of Patients.

22.  Records are an important tool in controlling and
assessing work; they are kept to help the supervisor to:
- Learn what is taking place
- Make effective decisions
- Assess progress towards goals
- Provide an insight for replanning purposes
 Records are the administration’s memory.
 Reports are the information communicated to the other
levels of the health services. They are also an important
management tool to influence future actions.

23.  The legal importance of records and reports are
explained under 3 approaches:
 INDIVIDUAL APPROACH
 COMMUNITY APPROACH
 NURSING APPROACH

24.  INDIVIDUAL APPROACH:
Birth & death report, individual health card, green card
(sterilization certificate), immunization chart, maternal
description etc. all records and reports have legal
importance. Not only in the field of health but in all fields
of life, individuals get facilities and legal protection on
the basis of records.

25.  COMMUNITY APPROACH:
- Health records provide confirmation, evaluation and protection of
basic rights of citizens, related to health. Records and reports
present the legal basis through which charges can be levied against
medical administration and political system, for health problems
prevalent in the community, shortcoming in the implementation of
health programmes, mistakes in the evaluation, and medical &
administrative inactivity.
- Public litigation can also be filed and administration can be made
responsible for the better implementation of health programmes
under legal protection.
- Irresponsible people , organizations and enterprises can be punished
for not following the health regulations.
- Proper recording and maintenance of community health
records and reports is essential to achieve all this.

26.  NURSING APPROACH:
- Preserving the individual and family health records of
the patients. Adopting the right method of filling.
-Maintaining the confidentiality and privacy of the
records of abortion, MTP, use of contraceptives and
STI &RTI’s.
- Records should be shown to authorized persons only.

27. - Presenting the record at the right time, in case of
consumer protection law or for any other court work,
preparing a register for it and protecting the parent
health organization/ agency against contempt of court.
- For destroying obsolete records, legally acceptable
process should be used.
- Records related to medico-legal cases, Death
declaration and will etc. should be handled carefully
for giving witness, whenever needed.

28.  Its content (statistical information on births, deaths,
morbidity or comments on program developments or
difficulties), and its frequency and utilization will differ
from country to county.

29.  In assessing the quality of care and the use of services
that are delivered to clients, health agencies rely on the
client’s record.
 Records should be accurately accessible and useful. In
other words, they must be truly available when needed,
and contain information that management uses as a
yardstick.

30.  In all health work it is important to keep sufficient
records to record is to remember.
 Public health records serve to communicate
information between different health workers.
 Recording is the basis for measuring diseases and
activities.

31. • SOAPIER - is an acronym used to designate the
recording process, with a notation made for each of the
letters.
S - Subjective data
O - Objective data
A - Assessment
P - Planning
I - Implementing
E - Evaluation
R - Reassessment

32. • Accurate
• Legible
• Complete
• Short and clear
• Timeliness

33.  Records & Reports are the essential components of
implementation and evaluation of health activities.
Some of the important facts related to the filling and
maintenance of records and reports are as follows:

34. 1) Filling of Records: Records can be kept in many ways.
 It is essential to have proper and systematic filling of
records.
 Properly filed records save time and effort.
 Filling of records depends upon the objective and method
adopted by the health agency or enterprise.
Methods of filling the records are:
(I)Alphabetically
(II)Numerically
(III)Geographically

35. 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.

36. Report can mainly 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 according to the name of those
who started the work or the first letter of activity.
4. Number: Reports can be expressed or filed according to
numbers or in serial order, like Report No. 1,2,3,4…..etc.

37. 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.

38. 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.

39.  The Nurse should take following precautions in the
maintenance of reports and records:
1. These should be kept carefully at a clean space.
2. These should be protected against mice, termites and
insects etc.
3. 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.

40.  Record and report are mutually interdependent. Report
can be prepared on the basis of records. Similarly the
report can be presented as record. Health record is a
form of information procured from the individual,
family and community. On its basis, doctors and nurses
can provide maximum possible health facilities to
them.