2. INTRODUCTION
Accurate documentation of patient symptoms and
observations is critical to proper treatment and recovery.
Entries written in a patient’s medical record are legal,
permanent documents. If documentation is poorly or
inaccurately entered into a medical record, the patient may
receive improper or potentially harmful care. Physicians and
other health care providers use what you document as fact in
a resident medical record, to plan, implement, and evaluate
the patient’s course of treatment.
3. DEFINITION
RECORD
“Record is written or computer based used for specific
purposes in any form. The process of making an entry on a
client’s record is called recording, charting, or documenting.”
Jogindra Vati.
4. “ Record are formal legal, administrative tools that
permanently document information relevant to direct
and indirect patient care”.
5. REPORT
“ Report is a oral, written, or computer based
communication intended to convey information
to others.”
Jogindra Vati.
6. “ A report is a system of communication aimed
at transferring essential information necessary
for safe and holistic patient care.”
7. OBJECTIVES OF HOSPITAL RECORDS
To review patient care, take appropriate
clinical decisions and to develop treatment
plans.
To provide an archival and legally acceptable
record.
To provide material for researchers.
To act as a source of information for health
administrators.
8. To enables for hospital auditing.
To carry out the things in right possible manner.
For statistical purposes.
To use for teaching and diagnostic purposes.
To use for legal purposes.
9. PURPOSES OF MEDICAL RECORDS
TO PATIENTS
To improve the patient care.
To serve to document clinical case history.
It serves to avoid omission or repetition.
10. Assists in continuity of care.
Its serves as evidences in medico – legal
cases.
It supplies necessary information to institute
an employees.
11. TO THE HOSPITAL
To document the type and quality of work.
To furnish proof of type and quality of care.
To protect hospital in legal situations.
To evaluate proficiency of staff.
To help in future programme planning.
12. PURPOSES OF PATIENT RECORDS
Communication.
Planning client care.
Auditing health agencies.
Statistical and research.
Education.
15. TYPES OF CHARTING OR FORMATS
OF RECORDING:
NARRATIVE CHARTING.
SOAP CHARTING.
PIE CHARTING.
FOCUS CHARTING.
16. VALUE OF NURSE CLINICAL RECORDS
To provide baseline data for further plan of action
and to evaluate the care given.
For diagnostic and treatment : Nursing records e.g.
temperature graphic record, blood pressure record
intake /output records etc can be used for
diagnostic purposes.
17. To evaluate the work load: this will help for
calculation of manpower required in that
particular setting.
To evaluate the quality of care.
To scientific and research purposes.
For legal purposes.
18. FUNCTIONS OF RECORDS
Helping to improve accountability.
Showing how decisions related to patient care are
made.
Supporting the delivery of services.
Supporting effective clinical judgments and decisions.
19. Supporting patient care and communications.
Making continuity of care easier.
Providing documentary evidence of services delivered.
Promoting better communications and sharing of
information between members of the multi professional
health care team.
20. Helping to identify risks, and enabling early detection
of complications.
Supporting clinical audit research allocation of
resources and performance planning.
Helping to address complaints of legal processes.
21. Records should be punctual and not include
unnecessary abbreviations, Jargon, meaningless
praises or irrelevant speculation.
Use professional judgment to decide what is relevant
and what should be recorded.
Record details of any assessment and review
undertaken.
Include details of information given about care and
treatment.
Records should identify any risk or problems that have
arisen and show the action taken to deal with them.
22. PRINCIPLES OF GOOD RECORD KEEPING:
Handwriting should be legible.
All entries to records should be signed put the
data and time on all records.
Records should be accurate and recorded in
such a way that the meaning is clear.
Records should be readable.
23. Do not alter or destroy any records with being authorized
to do so.
Do not falsify records.
Be aware of the legal requirements and guidance
regarding condentiality of the records.
Be aware of the rules governing confidentiality in respect
of the supply and use of data for secondary purposes.
24. Follow organizational policy and guidelines when
using records for research purposes.
Do not disclose the information and should not leave
any records, either on paper or on computer
screens.
Be aware of, and know how to use, the information
systems and tools that are available.
Ensure the proper use of the system particularly in
relation to condentiality.
26. STEPS FOR DESIGNING THE RECORD
Constitute a committee. The members should
be head of department, hospital administrator,
nursing head, supervisor and nursing staff of
operational level.
Call a meeting and repeated meetings to seek
suggestions and prepare a rough draft of
record.
27. Pretest it for its validity.
Check the feasibility and utility by conducting a pilot
study.
Periodically evaluate the record.
28. RECORDS AVAILABLE IN THE
NURSING UNIT:
Patient record.
Assignment record.
Census record.
Inventories record.
Narcotics and medication record.
29. RECORDS AVAILABLE IN THE
NURSING OFFICE:
Attendance record.
Personnel record.
Employment record.
Evaluation record.
30. REPORT
DEFINITION:
“Report is oral, written, or computer- based
communication intended to convey information
to others. These can be formal or informal.”
Jogindra Vati.
31. “Reporting is the process of informing the
other staff about the patients and of other
events.”
Jogindra Vati.
32. TYPES OF REPORTING:
Change – of – shift report.
Telephone report.
Telephone orders.
Transfer report.
Incident reports or occurrence reports.
34. PRINCIPLES OF DATA ENTRY AND MANAGEMENT OR GUIDELINES
FOR QUALITY DOCUMENTATION AND REPORTING
Accuracy.
Completeness.
Correctness.
Confidentiality.
Act.
Conciseness.
Objectivity.
Organization.
Timeliness.
Legibility.
35. ROLE OF ADMINISTRATOR IN KEEPING
RECORDS AND REPORTS
The reports and records should be kept under safe custody.
No individual’s sheet is separated from the complete record.
Records should be kept in place, inaccessible to patients and
visitors.
No stranger is permitted to read the records.
36. Records are not handed over to the legally and
ethically obligated to keep in confidence all the
information’s provided in the records.
All records to be handled carefully. Careless handling
can destroy the records.
Protection from loss.
37. Filing should be done according to hospital system
such as alphabetically, numerically with index cards
and geographically.
Assess periodically to determine the use of the
record and re-examine for means of simplification.
All records are identified with the bio data of the
patients such as name, age, ward, bed number,
outpatient (OP) number, inpatient (IP) number,
diagnosis, etc.
38. Records are never sent out of the hospital without the
doctor’s permission. Reference is made by writing
separate sheets and sending to the agency that requires
them, e.g. reference letter, discharge summaries.
39. REFERENCE
Vati . Jogindra. Principles and practice of nursing
management and administration. 1st edition. New
Delhi; Jaypee Medical Publication;2013:652 - 655.
K. Deepak. A Comprehensive Text book on nursing
management. 1st edition. New Delhi; EMESS
Publication;2013: 412.
40. Dr. Kochuthresiamma Thomas. Nursing
Management And Administration. Kottayam;
Medical work publishers; 2011: 163- 172.
Available at doi: 10.19082/5439.
