Nursing Record and Reports

 All professional person need to be
accountable for the performance of their

duties to the public.
 Since nursing has been considered as
profession, nurses need to record their work
on completion.
 Records are a practical and indispensable
aid to the doctor, nurse and paramedical
personnel in giving the best possible service
to the clients.
 Reportsummarizes the services of the person
or personnel and of the agency.
A record is a permanent written
communication that documents information
relevant to a client’s health care
management.
A record is a clinical, scientific,

administrative and legal document relating
to the nursing care given to the individual
family or community.
A report is the summary of the services of

person or personnel and of the agency.
 Records are a practical and indispensable
aid to doctor, nurse and paramedical
personnel in giving the best possible service
to their clients.
 Recorded facts have value and scientific

accuracy for more than mere impression of
memory and there are guidelines for better
administration of health services.
 Supplydata that are essential for programme
planning and evaluation.
 Provide the practitioner with data required

for the application of professional services
for the improvement of family's health.
 Tools
of communication between health
workers, the family & other development
personnel
 Effective
health records show the health
problem in the family and other factors that
affect health.
 Nurses should develop their own method of
expression and form in record writing.
 Written clearly, appropriately and
adequately.
 Contain facts based on observation,
conversation and action.
 Select relevant facts and the recording
should be neat, complete and uniform
 Valuable legal documents and so it should be
handled carefully, and accounted for.
 Records should be written immediately after
an interview.
 Records are confidential documents.
 Accurately dated, timed and signed Not
include abbreviations, meaningless phrases
 For the Individual and Family Records serve
to document the history of the client.
 Records assist in the continuity of care.
 Records serve as evidence to support or to
manage or face the legal questions that
arise.
 Records serve to recognize the health needs
and can be used as a research and teaching
tool.
For the Individual and Family
 Records serve to document the history of the
client.
 Records assist in the continuity of care.
 Records serve as evidence to support or to
manage or face the legal questions that
arise.
 Records serve to recognize the health needs
and can be used as a research and teaching
tool.
For the doctor
 Serves as guide for diagnosis,
 treatment, follow up and evaluation of
services.
 Indicate progress and continuity of care.
 Help self evaluation of medical practice.
 Protect the doctor in case of legal issues.
Records may be used for teaching and
research.
For the Nurse
 Provide with documentation of services
rendered, i.e. shows health condition of the
client.
 Provide data essential for planning and
evaluation of services for further
improvement.
 Serve as a guide for professional growth.
Enable to judge the quality and quantity of
work done.
 Serve as communication tool between staff
and other members involved in care.
Indicate plans for the future.
For Authorities
 Provide the management with statistical
information necessary for decision in regard
to utilization of resources, planning for
administrative control and future references.
 Help the supervisor evaluate the services
rendered, teaching done and a person’s
action and reactions.
1) Cumulative or continuing records -This is
found to be time saving, economical and also it
is helpful to review the total history of an
individual and evaluate the progress of a long
period.
2) Family records - All records, which relate to

members of family, should be placed in a single
family folder. Gives the picture of the total
services and helps to give effective, economic
service to the family as a whole.
3.Student Record - Application forms and other
reports called for at the time of recruitment
,selection and appointment such as reference
medical report , school records rsult of any test
carried out at a time of selection.
4.Faculty Record -Job discription and workload ,

record of faculty member and their educational
qualification previous experience ,any short term
course attended , memebership in professional
activities , leave record etc.
5.General Record - written policies of the
college in various areas like library , mess
,Discipline, visiting time , ward duty , class
hours ad INC reports etc.
1.Forms, case cards and Registers.
 Family record
 Eligible couple and child register
 Sterilization and IUD register
 MCH Card/ register
 Child Card/ register
 Birth and death register
 Sub centers/PHC/clinic register
 Stock & Issue register
 Reports of blood test of Malaria and Filaria
 Malaria parasite positive case register and
others
 The patient’s clinical record
 Records of nurses’ observations – Nurses’
Notes
 Records of orders carried out
 Records of treatment
 Records of admission and discharge
 Records of equipment loss and replacement
( inventory)
 Records of personnel performance.
 The Head Nurse’s Responsibility for the Clinical
Record
 Protection from loss -
The head nurse is responsible for safeguarding the
patient’s record from loss or destruction. No
individual sheet is separated from the complete
record unless, as with the doctor’s order sheet, it
is kept in a special place where its safety is
guarded.
Safeguarding its content
The hospital administration usually has a
procedure with which the head nurse should be
familiar for handling legal matter of this kind.
Patient has the right to insist that his record be
confidential.
 Completeness -
Compile records with complete identifying
data on each page in the form approved by the
hospital. The two parts of the record for which
the nursing service is universally wholly
responsible are the vital sign, graphic sheet
and nurses’ observation or nurses’ notes.
Responsibility for nurses’ notes -
The form for nurses’ notes which has been
established by the hospital should be used by
all nurses.
 Reports can be compiled daily, weekly,
monthly, quarterly and annually.
 Report summarizes the services of the nurse
and/ or the agency.
 Reports may be in the form of an analysis of
some aspect of a service.
 These are based on records and registers and
so it is relevant for the nurses to maintain
the records regarding their daily case load,
service load and activities.
 Thusthe data can be obtained continuously

and for a long period.
 Reports are information about a patient
either written or oral.
 A report is a summary of activities or
observations seen, performed or heard.
 To show the kind and quantity of service
rendered over to a specific period.
 To show the progress in reaching goals.
 As an aid in studying health conditions.
 As an aid in planning.
 To interpret the services to the public and to
other interested agencies
 Can be made promptly
 Clear, concise and complete
 All pertinent, identifying data included -
Mention all people concerned, situation and
signature of person making report
 Easily understood
 Important points are emphasized
 Can be made promptly
 Can be made promptly
 Clear, concise and complete
 All pertinent, identifying data included
 Mention all people concerned, situation and
signature of person making report
 Easily understood
 Important points are emphasized
 Oralreports : Oral reports are given when
the information is for immediate use and not
for permanency. E.g. it is made by the nurse
who is assigned to patient care, to another
nurse who is planning to relieve her.
 Written reports : Reports are to be written

when the information to be used by several
personnel, which is more or less of
permanent value, e.g. day and night reports,
census, interdepartmental reports, needed
according to situation, events and
conditions.
 Change of shift report
 telephone reports
 Telephone orders
 Transfer reports
 Incident reports
 Legal reports
1. Change- of- shift reports or 24 hours
report
 Provide only essential background
information about client (name, age sex,
diagnosis and medical history) but do not
review all routine care procedures or task.
 Identify clients’ nursing diagnosis or health
care problems and other related causes
 Describe objective measurements or
observations about clients’ condition and
response to health problems. Stress recent
change, but do not use critical comment
about clients’ behavior
 Share significant information about family
members, as it relates to clients’ problems.
 Continuously review ongoing discharge plan.
Do not engage in gossip.
 Describe instructions given in teaching plan
and clients’ response.

Nursing Record and Reports

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Nursing Record and Reports

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 All professional person need to be

accountable for the performance of their

A record is a clinical, scientific,

A report is the summary of the services of

 Recorded facts have value and scientific

 Provide the practitioner with data required

2) Family records - All records, which relate to

4.Faculty Record -Job discription and workload ,

 Thusthe data can be obtained continuously

 Written reports : Reports are to be written

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