Records and Reports

Records 

A record is a written communication in which the document information is in a systematic manner, for use in the present and future situation. They are the guidelines and valuable resources for legal implication which includes the clinical, scientific, administrative, and legal document.

Health records

These refer to the forms on which information about client i.e. biography, socio-economy, psychological, environmental, disease process, treatment, and management are recorded.

Purposes of Records:

• Records provide data for program planning and evaluation.
• They are the tools of communication between the health personnel, family members, and other concerned personnel.
• It guides the plan for the future.
• Records provide a baseline to estimate long-term changes to the service.
• Records provide an opportunity for evaluating service and future planning for better services.
• Records help in a research process.
• It serves the legal document as needed.

Types of Records

• Organization chart
• Policy, rules, and regulations.
• Procedure manual.
• Standing orders.
• Attendance and leave-off form
• Client’s record (admission discharge)
• Job description.

Importance of Record:

For nurses:

• They provide documentation of rended by the nurses.
• Provide data essential for planning and evaluation of services or further improvements.
• Serves as a guide for a professional goal.
• Enable to judge the quality and quantity of work done by health team.
• Services as a communication tool among staff and health care team members.
• Provides the babies for staff development activities.

For authorities:

• Provide the management with statistical information necessary for decision in regard to utilization of resources, planning for administrative control and future reference.
• They furnish documentary evidence for proposals of evaluation of care in terms of quality, quantity and adequacy.
• Helps the supervisors, to evaluate the services provided by the staff’s, patient’s reaction towards these services.
• Records help in guidances and conference to the staff and student by the supervisors.
• Helps to assess and analyze the health needs of people.
• Helps to compare the previous situation, existing situation and future plan.
• Helps in making studies for research to develop legislative actions and budget planning.
• Provide justification of expenses.

Reports

Reports are oral or written exchanges of information started between organizations, caregivers, or workers in a number of ways. Reports are usually written as shift reports, daily reports, weekly, monthly, quarterly, and yearly. They can be oral or written reports. The oral report is given when the information is for immediate use and not for permanency. For example- oral reports given by nurses on shift change to charge.

Written report

They are used when the information is to be used by different personnel having more or less permanent value. For example- census reports, interdepartmental reports, consultancy reports, etc.

Reports used in hospitals 

• Change of shift report, patient transfer report, patient’s progress report, investigation report, etc.
• A process of recording and reporting.
• It involves the following phases.

Preparation phase

It is the phase in which thinking, selecting, and writing facts clearly, concisely, and correctly in simple and understandable language.

Compiling phase

Systematic category-based information is compiled for easy access.

• Storing phase

Storing and preservation of all compiled records and reports are done separately in a proper manner that should be available and accessible at any time. It should be done by trained staff. Confidentiality should be maintained while storing.

• Discharge phase

All the records and reports need to be discharged routinely as per the policy of an organization. Discharging and discarding records and reports should be done by an authorized committee of the organization.

Nursing responsibility for record-keeping and reporting

• Nurses have a legal responsibility per accurate recording and reporting of patient’s condition, treatment given and responses to the care given.
• The medical record is an information source document that should be used to plan care, evaluate, allocate costs, educate personnel, perform resources, and substantiate legal claims.
• It is the property of the health care agency. Thus, they must be factual, functional, completely accurate, systematic, and organized. They should include and prepare as follows:

Fact

A record should contain descriptive, objective information. What the nurse sees, ’ hears, feels, and smells, in the same way, as anything happened during managing affairs in the institution. A manager should document inferences with factual information to avoid misleading and errors in administration.

Information

The information must be accurate and reliable so that health team members have confidence.

Completeness:

Information should be complete and concise about client care or any other event happening in the situation.

Correctness

Delays in recording can result in serious problems. Incorrect medical and nursing care or any legal action. A late entry in the patient chart may be interpreted as negligence.

Organized

The information must be kept in a logical manner so that the health team members understand.

Confidentiality:

Nurses are legally and ethically obligated to key information about the client.