RECORDS AND REPORTS

FEBRUARY 13, 2019  NURSING PATH  NO COMMENTS

   Records is an account of something, written to perpetuate

knowledge of events. Records and reports and indispensable aids to all who are responsible
for giving best possible service to individuals, families and community. Good reports are
time savers. They prevent duplication of work, decrease errors and show efficiency level of
the staff.
   Records and reports hold an important place in the process of educational administration.
The teacher should prepare records and reports after implementation of a plan over project
and the educational administrator himself is expected to prepare a report about the
organization and its function periodically.
   An educational institution is a composite of many activities of varied type. It is difficult for
anybody to remember the details of those activities. Recording those activities in the
registers regularly and then maintaining them is an essential duty of the administrator.
Further, he/she has to make the record of student's achievements, rewards, punishments.
And keeping the account accurate and up to date is another record essential in
administration. 

Characteristics of good Recording and Reporting:

1. Accuracy: Information should be correct to prevent serious mistakes. Use of correct

spelling and the institutions accepted abbreviation and symbols ensure accurate
interpretation of information. It should be always complete with accurate signature.
Do not use nick names.
2. Conciseness: Use a few words as possible to give the necessary information.
3. Thoroughness: Even a concise record or report must contain complete information.
4. Up to date: Recording should be done on time. A definite time and routine for the
reporting make more time and routine for the reporting makes more efficient
management. Delay in recording can result in serious omissions and delay the work.
5. Organization: Communicate all the information in a logical format or order.
6. Confidentiality: The information should be confidential.
 7. Objectivity: Presentation of facts not personal feelings, to give true picture.

Importance of Records and Reports:

The importance of records can be describe under following heads:
1. Importance of records for patients

 Legal evidence
 It avoids duplication of treatment measures
 It avoids duplication of diagnostic and procedural measures
 It will assist in continuity of patient care
 It helps in health insurance of the patient

2. Importance of records for doctor 

 Assure quality of care

 It will help in evaluation of medical care given by doctors
 It protects the doctor from legal activities 

3. Importance of records for hospital

 Legal protection of hospital

 Evaluate medical care given by doctor 
 Evaluate performance of individual doctors
 It also assist in planning and justification of resources

4. Importance of records for public health

 Helps in early warning of epidemic and communicable disease

 Assist in planning preventive and social measures
 Provide information of vital statistics like mortality rate, morbidity rate, infant death
rate etc.

5. Importance of records in education and research

 Forms basis of clinical research

 Aids in formal education of students and staff
 Reliable source of material for advancement in medical science.

Purposes of Keeping Records

 Communication
 Education
 Assessment
 Documentation of continuity and justification of case
  Research
 Auditing
 Legal documentation
 Individual case study

   Records and reports play an important part in nursing education programme. Apart from
being necessary for the day to day administration of school of nursing; they provide
continuity from the time the school is established, thus facilitating evaluation of the
programme. 

Types of Records
They types of records usually kept in a school office may be divided into 3 categories.
1. Those concerning students:

 Application forms and other reports called for at the time of recruitment, selection
and appointment, such as references, medical reports, school records and result of
any test carried out at the time of selection.
 A record of each students clinical performance.
 A progress report showing grades and other pertinent information.
 A final record/permanent record giving a summary of instruction, clinical experience,
grades and relevant material.
 A health record.
 Admission record.
 Anecdotal record.

   Records and Reports for INC

1. Admission register
2. Students attendance register
3. Clinical experience records
4. Students health records
5. Staff attendance records
6. Acquittance register
7. Internal assessment register
8. External marks register
9. Report of various committee

2. Records concerning school staff:

    In the personal file of each staff member, there should be the following:

 Application forms.
 Copy of letter of appointment (or posting order) and any subsequent letter showing
changes in status.
  Job description what candidate is expected to do in each category.
 Record of staff member's educational qualification, previous experience, any short
term educational courses attended, membership in professional society such as
contribution of articles in journals, holding office in associates or organization,
participation in seminars, conference etc.
 Periodic evaluation or progress report.
 Leave record.
 Health record.
 Anecdotal record.

3. General school records:

    These consist of :

 The philosophy, objectives and curriculum of the school.

 Written policies of the school.
 Statement of budget proposals and allotments.
 Letters of agreement with affiliating agencies.
 Minutes of staff meetings.
 Copy of school brochure (or prospectus).
 Inventories of stocks.
 Admission.

REPORTS

   The number and nature of reports will be depending on what is required by the controlling
body and nursing council.
   The type of information which is commonly required in an annual report is as follows:

1. Factual data relating to students, staff, clinical facilities, physical facilities,

administration and curriculum.
2. Developments made in the school programme since the last report.
3. Proposals and plans for future developments.
4. Recommendation.

Role of Administrator  
   The nurse administrator should see that every body is following common guidelines for
recording information:

 Information recorded is true and complete.

 Entries should be legible and written in link.
 Only facts should be recorded.
 Entries should be brief, accurate, legible and correctly spelt.
  If item error is made while written, the nurse should not erase or overwrite, instead
draw a single line over it and sign it. Then note it down correctly.
 Do not leave blank space in a note.
 Always make chart for yourself and never for someone else.
 Should write in chronological order of date and time.
 Each page of record should be properly identified with identification data. 

Keeping records and reports is an important responsibility of the nurse administrator. The

main points include:

 The records and reports should be kept under safe custody.

 No individual sheet is separated from the complete record.
 Records must place confidentially.
 No stranger is permitted to read the record.
 All records to be handled carefully.
 Protection from loss.
 Filling should be done alphabetically, numerically with cards and geogra-phically.
 Assess periodically to determine the use of record and reexamine for means of
simplification. 

   Keeping records and reports is necessary activities in every administrative and

educational programme. reports also serve as a source of reference and it has legal value
too. The nurse administrator should see her role in maintaining records and reports in
nursing education in order to save time. The form of record should be simple and easy to
fill.