RECORDS AND REPORTS Introduction:

Historically, nurses have had an easy relationship with nursing documentation. Although the quantity of nursing documentation certainly has increased over the years, the same cannot necessarily be said about the quality of information documented. We are living in an era of consumerism,accountabilityand quality assurance. Today the nurses are accountable to the clients for the care provided as providers of services, and on the other hand consumers of health care are demanding for quality of care in any setting and all over the world.

Records
A record is a clinical, scientific, administration and legal document relating to the nursing care given to individual family or community. ecord is a permanent written communication that documents information about a patient and his medical and nursing management. ecording is the communication, in writing, of essential facts, in order to maintain a continuous history of events for a period of time. Purposes o !rovide data for programme planning and evaluation. o ecord are the tools of communication between health wor"ers, family and other developmental personnel o #ndicate plans for future o !rovide baseline data to estimate the long term changes related to the service. o !rovide an opportunity for evaluating the services o Helps in research for improvement of nursing. Principles of record writing $. %urses should develop their own method of e&pression and form in record writing. '. ecord should be written clearly, appropriately and legibly (. ecord should contain facts based on observation, conversation and action. ). ecording should be brief and accurate. *. ecords should be neat, complete and uniform. +. ecords are valuable legal documents and so it should be handled carefully and accounted for. ,. ecord systems are essential for efficiency and uniformity of service -. ecord should provide for periodic summary to determine progress and to ma"e future plans. .. ecord should be written immediately after an interview. $/. ecords are confidential documents. $$. 0se only standard abbreviations Characteristics of good recording and reporting Accuracy: information should be correct. All information should be correct to prevent serious mista"es in giving continued nursing care. 0se of correct spellings and the institution1s accepted abbreviation and symbols ensure accurate interpretation of information. Always complete a descriptive entry in the client1s record with an accurate signature. 2o not use nic" names. Conciseness: use as few words as possible to give the necessary information. Thoroughness: even a concise record or report must contain complete information about a client

Up-to-date3 recording should be done on time .a definite time and routine for the reporting ma"es for more efficient management of the word. 2elay in recording can result in serious omission and delay the needed care. Organization: communicate all information in a logical format or order. Confidentiality the nurse is legally and ethically obliged to "eep information pertaining to client1s illness and treatment as confidential. Objectivity: presentation of facts and not personal feelings to give a true picture. T pes of records ecords can be mainly categori4ed in four ways5 $. !eriodically6 !ermanent records e.g. cumulative record 6 Temporary record e.g. casual7daily record '. 0nit based 6 #ndividual e.g. individual health card elated to family e.g. family folder elated to community e.g. record of health problems %ational. 8.g. national health programme record (. 9ub:ect based ;8conomical e.g. financial structure of family. 6 9ocial e.g. records of social structure 6 !olitical 6 <edical and nursing e.g. treatment ,medicine ). =ollection place based ; =ollected at institution e.g. records of health centre 6 ecords to be "ept with the individual e.g. immuni4ation card. !ses of records 8ffective means of communication Help in providing best possible service to the individual, family and community. =an save effort and money The health wor"er can save effort and money The health wor"er can organi4e the wor" and ma"e the most effective use of his time. 0seful in research =an be useful as an instrument of health education Records in co""unit setting3 The "inds of records that are normally "ept will vary with the activities. They include the following5 $. >illage record '. ?amily folders, household and family records and individual health cards. (. 8ligible couple records. ). ?amily planning record e.g. record of #02, condom. *. <aternal and child health record @including anc, pnc, child care, nutrition, immuni4ationA +. Tuberculosis card ,. Beprosy record -. <T! record .. 9T27H#> survey record $/. ecords related to =H $$. 9chool health record $'. Cirth and death register $(. Dutdoor attendance register $). Dperation register $*. #ndoor patient register $+. ecords of medical care

$,. 9toc" register $-. <onthly reports $.. 2aily dairy '/. %urses notes '$. %ursing audit ''. !roblems oriented medical records. Care of records These should be "ept under safe custody %o stranger should be permitted to see the records. These should be complete and arranged data6wise. All records should be arranged alphabetically, numerically with inde& cards. These should be stored after discharge of the patient, in the record room. ecords are not sent outside hospital without doctor1s permission. Record #eeping $. Source records3 the information is grouped according to the source or information contributed by healthcare department. '. Proble oriented records3 it is based on scientific problem6solving system. (. !ursing carde"3 the information needed for the daily care is accessible from the card and is "ept filed #$ Co puterized infor ation syste Co"puteri$ed docu"entation %urses have been using computeri4ed systems for supplies, equipments, stoc" medications and diagnostics testing for sometime. There is now a rapidly growing trend for computeri4ed documentation, these are drastically changing. <any computeri4ed systems have been developed in standardi4ed formats with the ability to gain access across the continuum easily and the ability to capture useful information from both individual clients and population groups. =omputers provide several ad%antages over paper based record system. #nformation can be stored in smaller areas, search and analytical tas"s can be done and information can be obtained in a faster and efficient manner. #n nursing, usage of computers can be divide into ( ma:or categories5 =linical system6 data about patient can be entered5 computer can sort and analy4e data and facilitate communication about patients among health care providers. <anagement information system ; can be used for patient1s classification, supplies and material management, staff scheduling policy, procedure changes, announcement, budget information and management, personnel records, statistical reports, administrative reports. 8ducational system6 computers can be used for giving instructions to the students. &enefits of auto"ated speech'recognition (ASR) technolog . o =omprehensive nursing documentation with minimal nursing effort o 2ecreased charting errors and omissions. o =onsistent documentation patterns. o #ncreased interdisciplinary communication. o =onsiderable time savings for the nurse. o =lear, concise, legible documentation. O*+ecti%es of co"puter *ased patient care recording (CPCR) #mproved uniformity, accuracy and retrievability of data about client care. =onfidentiality of health care information ensured in the system. Access for authori4ed health care providers from any department

Ability to retrieve information selectively and choose various formats for e&amining it. Assistance with clinical application, including analysis tools, ris" assessment and clinical reminders. 9upport for data collection in a manner that adequately supports health care provider1s direct entry and stores information according to a defined vocabulary. 8asy access to client data, fast retrieval and versatile data display that facilitates improved health care delivery. Availability of a lifelong record of health6record events in corpora ting records from various settings and time periods.

There is legal ris" associated with computeri4ed documentation. Any given person could theoretically access a computer station within a hospital and gain information on almost any client. =onfidentiality of access to computeri4ed records is a ma:or issue. 9ecurity requires the use of a password to enter and sign off computer files. A good system requires periodic changes in personal passwords to prevent unauthori4ed persons from tampering with records. %urses need to "now how to correct charting errors on a computer. #ncorrect entries must be corrected, indicating who made the correction and when. The transition to computeri4ed documentation presents both opportunities and challenges to nurse and nurse managers. The successful implementation of a computeri4ed documentation system requires preparation, involvement and commitment of entire nursing staff

Reports
eports are oral or written e&change information, shared between nurses in a number of ways. 2uring shifts, verbal handing6over and ta"ing6over is done by giving oral report about each patient. eporting is the communication of information to another individual and may be written or oral. Purposes: Written report5 $. To show the "ind and amount of service rendered over a specified period. '. To illustrate progress in teaching goals. (. #t acts as an aid in studying health condition. ). #t acts as an aid in planning. *. To interpret the service to the public and other interested agencies. A good narrative report provides an opportunity to pursuit problems for administrative considerations. $. Eood reports are time savers. They prevent duplication of wor". '. 2irect influence on the progress and even life of patients. (. !rovide a sense of security and confidence to the nurse in doing her wor" giving a good report is an act. Ele"ents of report: Timings3 most pertinent time, an accident or change in a person1s condition. Organization3 important points are mentioned in logical order and stand out from the e&planatory and supporting statements. Clarity3 leaving no doubt of what happened, what was done or what remains to be done. Brevity3 omit unnecessary words and statements for a clear, complete picture. Correctness: to prevent serious mista"es in giving continued nursing care. Objectivity: presentation of facts, not personal feeling to give a true picture.

T pes of reports Dral reports ; an oral report is made by the nurse who is assigned to patient car to another nurse who is supposed to relieve her. Written report ; description and conclusion of action the influence further planning and decision ma"ing are necessary. ') hours report ; supervisory and nursing administrative personnel need to be "ept informed of what is happening in all patient care areas. =ensus report ; helps in planning of health care services and "nows about more and more standards. Accidental report ; writing a detailed report on mista"es or accidents that has ta"en place in care of patients. =hange of shift duty. Transfer report ; it involves communication of information about clients from nurse to nurse on receiving unit. Dther report ; reports among the members of nursing team, report between head nurse and her assistant, report between head nurse and nursing superintendent. ,egal i"plication in record and report "aintenance #nformed consent is essential before surgery or investigation for the patients. =onfidential records and reports should be shown to authori4ed persons only egistrations of births, deaths and still births are the important vital events. <edicines should be administered as per the order of physician and also under supervision =hec"ing of labels appearance of drug also should be charted accurately before administration. ecording and reporting accidents, errors and incompetent behaviors. #dentification of babies in labor ward by dis"s. #dentification of dead bodies in mortuary. Role of co""unit health nurse in recording and reportingecords and reports are the essential components of implementation and evaluation of community health activities. #t is necessary for the community health nurse to have thorough "nowledge of their maintenance. Securing record information: ecords are started in the centre or in the home at a time when the individual is see"ing some service or when the health wor"er recogni4es the need for service. The record should show chronologically to what e&tent progress is being made towards the goal of better health for the individual and the family. this is particularly important in regard to better nutrition and sanitation. The individual and family co6operation in ma"ing out the record is important. Record filling =orrect filing of records is essential, some agencies file records alphabetically and other use numerical system. Precautions in maintenance3 The community health nurse should ta"e following precautions in the maintenance of records and reports, The records should be "ept carefully at a clean place. The records should be protected from from mice, termites and insects etc.

 Eood filing system should be developed for the records and reports. ecords should be easily available on time. =onfidential record and report should be shown to authori4e persons only.

School health records: #t is essential to maintain complete, accurate and continuous health records of school children, it also helps to evaluate the school health services and assist in further development and improvement of health services rendered to school children. #t should include information about identification and personal aspect, personal and family health history, findings of physical and medical e&amination, finding of routine investigations and screening and services rendered and the prognosis. Conclusion: All professional persons need to be accountable for the performance of their duties to the public. 9ince nursing has been considered as profession, nurses need to record their wor" on completion. ecords and reports are effective communication.

REFERENCES 1. Potter PA, Perry AG. Fundamentals of Nursing. 6th edn. Mosby; st Louis.2 !.

'. C T Casavanthappa.%ursing Administration. %ew 2elhi3 :aypee brothers3 '//'. (. C T Casavanthappa. =ommunity health nursing .'nd edition. %ew 2elhi3 :aypee brothers3 '//-.

). 9warn"ar "eshav. =ommunity health nursing.'nd edition. #ndoor5 nr brothers3 '//,. *. !ar" " " te&t boo" of preventive and social medicine.$,th edition.delhi5 :aypee3 '//,. +. Famala s. 8ssential in community health nursing practice.$st edition.newdelhi5 :aypee brothers3 '//*. ,. www.google.com
8. Website www.crnns.ca