Records and Report

INTRODUCTION:
Reporting and recording are the major communication techniques used by health care providers. Presenting
the facts, data, figures and other information in writing is called records. Record is the written presentation
of information. Report is the written or verbal communication root.
DEFINITION OF RECORD:
It is a written communication that permanently documents information relevant to a client’s health care management.
It is a continuing account of the client’s health care needs [ Sr. Mary lucita ]
DEFINITION OF REPORT:
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 ]
PURPOSES OF CLIENT’S RECORD CHART:

 Communication: Provides efficient and effective method of sharing information.
 Legal Documentation: It is admissible as evidence in a court of law
 Research: Provides valuable health-related data
 Statistics: Provides statistical information that can be utilized for planning people’s future needs.
 Education: Serves as an educational tool for students in health discipline.
 Audit & Quality: Monitors the quality of care received to the client and the competence of health care givers.
 Planning: Client Care Provides data which the entire health team uses to plan care for the client.
PURPOSES OF REPORT:
 Report is an essential tool for communication
 To show the kind and amount of services rendered over a specific period.
 To illustrate progress in teaching goals.
 As an aid in studying health condition.
 As an aid in planning.
 To interpret the services to the public and to the other interested agencies
CHARATERISTICS OF A GOOD RECORD:
 Accuracy 
 Consciousness 
 Thoroughness 
 Up to date 
 Organization 
 Confidentiality 
 Objectivity
CHARATERISTICS OF A GOOD REPORT:

 Made promptly.
 Clear, concise, and complete.
 If it is written all pertinent,
 Identifying data are included-the date and time, the people concerned, the situation, the signature of the person
making the report.
 It is clearly stated and well organized
 Important points are emphasized.
 In case of oral reports they are clearly expressed and presented in an interesting manner.
METHOD OF RECORDING:
 Narrative Charting (TRADITIONAL CLIENT RECORD)

o Describes the client’s status, interventions and treatments; response to treatments is in story format.
o Narrative charting is now being replaced by other formats.
o Five Basic components of a Traditional Client Record 
o Admission sheet 
o Physician’s order sheet 
o Medical history 
o Nurse’s notes 
o Special records and reports (referrals, X-ray, reports, laboratory findings, report of surgery, anesthesia record,
flow sheets, vital signs, I&O
 SOURCE ORIENTED RECORD:

o Each person or department makes notations in a separate section/s of the client’s chart.
o Narrative recording by each member (source) of the health care team on separate records.
o Most Traditional
o Different disciplines chart on separate forms
o Each reader must consult various parts of the record to get a complete picture
o Records become bulky
o For example the admission department has an admission sheet, nurses use the nurses’ notes, physicians have a
physician notes, etc….
 PROBLEM FOCUSSED CHARTING:

 Problem-Oriented Medical Record( POMR) /Nurse’s or narrative notes (SOAPIE format)
Uses a structured, logical format called S.O.A.P/ SOPIE/ SOAPIER:
S- subjective. What pt tells you.
O-objective. What you observe, see.
A- assessment. What you think is going on based on your data.
P-plan. What you are going to do. Can add to better reflect nursing process
I- intervention (specific interventions implemented)
E- evaluation. Pt response to interventions.
R-revision. Changes in treatment.
Uses flow sheets to record routine care.

SOAP entries are usually made at least every 24 hours on any unresolved problem.
 APIE(PIE) CHART:
A- Assessment
P- Problem identification
I- Intervention
E- Evaluation
 The process begins with an admission assessment that is usually completed on a separate form and the initiation
of a problem list that is based on the initial assessment.
 Documentation of client care is focused on intervention and evaluation related to problems listed.
 Each entry in the progress note is preceded by the date, time and problems listed.
 Each entry in the progress note is preceded by the date, time, and problem number and it indicates whether the
entry is related to implementation or evaluation. Each problem is evaluated at least once per shift.
 Charting by Exception (CBE)
 The nurse documents only deviations from pre-established norms (document only abnormal or
significant findings).
 Avoids lengthy, repetitive notes.
 Computerized Documentation
 Increases the quality of documentation and save time.

 Increases legibility and accuracy.
 Facilitates statistical analysis of data.
 Case Management Process
 A methodology for organizing client care through an illness, using a critical pathway.
 A critical pathway is a multidisciplinary plan or tool that specifies assessments, interventions,
treatments and outcomes of health related problems a cross a time line.
METHOD OF REPORTING:
1. Written
2. Verbal
TYPES OF RECORDS:
1. Outpatient and inpatient records

2. Nurse’s recording
3. Doctor’s order sheet
4. Graphic chart of TPR
5. Reports of laboratory examination
6. Diet sheets
7. Consent form for operation and anesthesia
8. Registers
9. Medico-legal cases- documentation
10. Medication record
11. Daily nursing care record
12. Progress note
13. Nursing discharge/ referral summaries
14. Flow sheet
TYPES OF REPORTS:
 24 hours reports
 Census report
 Birth and death report
 Incidental report
ADVANTAGES OF RECORDS AND REPORTS:
 Monitoring operations
 Controlling
 Guide decision
 Employee motivation
 Performance evaluation
DISADVANTAGES OF RECORDS AND REPORTS:

 It is time consuming.
 Expensive
 Reports can be biased
 Sometimes implementations of the recommendations of a report become unrealistic.
 Technical reports are not easily understandable
NURSES RESPONSIBILITY IN RECORDING AND REPORTING:
 The records are kept under the safe custody of the nurse in each or department
 No individual sheet is separated from the complete record.
 Records are kept in a place, not accessible to the clients and visitors.
 No stranger is ever permitted to read the records.
 Records are not handed over to the legal advisers without the written permission of the administration.
 All records are to be handled carefully. Careless handling can destroy the records.
SUMMARIZATION:
Record keeping system are either handwritten or computerized and the format varies among health care agencies.
Increasingly sophisticated management information system are being utilized to manage client specific data and
information.reports are effective means of communication among the members of the health team. In a report an
account of something that has been seen, heard, done or considered is given.
CONCLUSION:
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.
BIBLIOGRAPHY:
 Nancy sr, principle and practice of nursing arts and procedures, 7 th edition, NR publisher, NR publishing house,
2017, page no216-223.
 Kaur Maninder, kaur lakhwinder, fundamental nursing, pee vee books, page no 84-91.
 Clement I, textbook of nursing foundation, 2nd edition, jaypee publisher, page no 130-133.
 https://www.slideshare.net/FIROZQURESHI/records-and-reports-64022438

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INTRODUCTION:

PURPOSES OF CLIENT’S RECORD CHART:

CHARATERISTICS OF A GOOD RECORD:

CHARATERISTICS OF A GOOD REPORT:

 Narrative Charting (TRADITIONAL CLIENT RECORD)

 SOURCE ORIENTED RECORD:

 PROBLEM FOCUSSED CHARTING:

Uses flow sheets to record routine care.

 Charting by Exception (CBE)

 Increases the quality of documentation and save time.

1. Outpatient and inpatient records

DISADVANTAGES OF RECORDS AND REPORTS:

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