PRACTICAL 8 FAMILY HEALTH

RECORDS
Structure
8.0 Objectives
8.1 Introduction
8.2 Principles of Recording
8.3 Health Records
8.3.1 Purposes of Maintaining Records
8.3.2 Importance of Records
8.3.3 ?Lpes of Records Maintained in a Health Centre
8.3.4 Equipment Required for Recording
8.3.5 Procedure
8.3.6 Filing of Records
8.3.7 Points to Remember

8.4 Let Us Sum Up

8.5 Answers to Check Your progress

8.0 OBJECTIVES
- - - -

After completing this practical, you will be able to:

a identify different types of records used in the health center and for field work;
a identify the sources of health information;
a list the methods followed for filinglstoring of records;
a record relevant health information accurately;
a explain to the family and patients about the usefulness and importance of
records maintained in the health center and records kept with them; and
a utilize standard forms for recording and reporting.

8.1 INTRODUCTION
Determining the results of the services delivered is one of the most important areas
for the health workers. Statistics of field programme shows the out come results of
the programme. The effectiveness of the programme, service or activity is
reflected in the achievement of the goals and objectives. Figures in the records
may not tell about the effectiveness of the actions, but it explains the results of the
actions. Community Health Nurse has the responsibility to record information as
accurate as possible and submit them timely as per prescribed guidelines. Records
serve as a basis for nursing interventions and as a means of communication among
workers regarding services rendered. When all team members are a part of the
health agency, they use the single record for one client. The health workers record
in a timely manner. Each member has access to record of recent encounter and
can plan for the next encounter accordingly.
 Family Health Records
8.2 PRINCIPLES OF RECORDING
There are some generally accepted guidelines to maintain the uniformity and
consistency of recording.
These guidelines are:
Record must be written neatly, clearly, accurately, appropriately and legibly.
Standard abbreviations must be used or the ones which are widely accepted.
Make the sentences short and clear.
Make entries at the time the services are delivered, with date time and
signature of the worker.
Care should be taken not to make any errors in the records if any thing is
crossed out it should be dated and initialed.
Records are written continuously with no blank spaces. If any space is left
out it should be crossed out, dated and signed.
Delivery of health services is not complete until the details of each activity have
been adequately recorded in appropriate forms, registers or records.

Note the following points about each contact with the client:

a) What did you find during the visit?

b) What treatment or advice did you give?

c) What changes did you observe from the previous visit?

d) Have any of your suggestions during the previous visit been implemented?

e) Note the date and time and plan for the next contact.

8.3 HEALTH RECORDS

Records and reports are necessary in rendering health services to people. They
are needed to:
Collect baseline information which could be used to plan programmes and
activities.
Get information about the types of health problems prevalent among the
community. I

I
Help in identifying the health status of the people.
Helps the health administration to assess the resources and health needs of
the community.
Help in research activities conducted in the community.
Provide justification of expenditure of funds.
Records help the supervisor to evaluate the services rendered and
performance appraisal of the workers.

8.3.1 Purposes of Maintaining Records

The main purposes of maintaining records are to:
Assess the health status of the community. 67
Nursing Practices in Collect health statistics.
Community Health-I
Assess the work done.

Plan health c m activities.

Promote economy of time and effort by preventing duplication of services.

Assess the requirement for vaccines, equipments and supplies.

Serve as a tool for health education to the individuallfamily and community.

Communicate information to other team members for continuity of care.

Evaluate the progress of health programmes and replanning of the activities.

Providing legal documentation for community health action when faced with
litigation charges.

8.3.2 Importance of Records

According to Morri (1975) the importance of records include following:

1) To study the effects of diseases states in populations overtime and predict

future health needs.

2) To diagnose the health of the community.

3) To evaluate health services.

4) To estimate individual risk from group experience.

5) To identify syndromes.

6) To complete the clinical, pictures so that prevention can be accomplished

before disease is irreversible.

7) To search for cause.

8.3.3 Qpes of Records Maintained in a Health Centre

There are various types of records maintained in the community to collect
information such as:

General information about the village, population information, facts and figures
and health related information, community profile.

Family folders these include detailed information about the family members,
individual health status cards and general information about the home environments
4
and living conditions of the family (Refer Appendix VII).

Maternal and child health cards these may also be the part of family folder,
these include antenatal cards, confinement record and post natal card, infant cards,
preschool cards and immunization card (Appendix VII).

Family welfare records these include information about the eligible couple, use of
contraceptive methods and sterilization (Appendix VII).

Vital events record birth and death records in the form of birth and death
registrations (Appendix VII).
Record of medical care and referrals these include records pertaining to
treatment of medical problems. Referral card includes information related to what
has been done and what needs to be done in the 5 t l ~ i r
Records of distribution of Iron, Folic acid tablets, Vitamin A concentrate. Family

Records of stocks received and utilized including issue and balance of drugs,
supplies, vaccines, contraceptives and stationery.

Supervisory records: These include record of meetings with health workers,

monthly staff meeting etc.

Monthly reports and statistics records: These records are maintained and sent
to the higher authorities by the Medical officer in charge of the health center.

Daily dairy for recording the daily activities it is not possible for the Community
health nurse to cany all the records for home or village visits. A notebook which is
called the daily dairy is used to record the events as it takes place and proper
record is filled up after returning to the health center.

A daily dairy includes immediate and incidental record of activities, record of

persons for whom worwservice is carried out and requires follow up or referral
services, records of matters which need to be discussed with the supervisor or the
authorities. The information should be recorded neatly, correctly and honestly
written.

Cumulative Records

Cumulative records have been found to be economical and time saving, For e.g.,
having one card for each growth period of child like new born, infant, toddler and
school child so that the continuous progress and health status of child can be
assessed.

Registers

Use of registers provides indication of total volume of services and types of cases
seen. Registers help in coordinating different activities and cumulative information
can be assessed at a glance. Once these registers are established it takes less time
to record and contains more information. Different types of registers are
maintained in each health agency and health team members contribute towards
maintaining these registers.

Registers are used to record the names of beneficiaries in the area such as
families, eligible couples, infants, preschool children.

Health Records Retained by Mothers or the Patients

These are some records which are retained by the families or the patients and
brought to the health agency or produced to the health worker during the visit.
Some of these records are:

Immunization cards

Infant card

Pre school card

Child health cards

Under 5 year of.age cards

Ante-natal card

TB or Leprosy patients card.

-
Nursing Practicces in These cards are useful because:
Community Ht:alth-I
Time is saved in finding out the card
It remains with the family or patient when moving from one place to the other

Aids in Health teaching during clinic or home visit

It helps to know progress and guide for next visit
Ready reference in any eventuality when you need to know the past health
status of the individuavpatient

8.3.4 Equipment Required for Recording

The various articles required for recording include following:
Pen - blue and red
Pencil
Eraser
F'rinted card for Recording
FileFamily Folder
Scale
Labels
Tags

8.3.5 Procedure
For effective delivery of health care services you must record each activity every
day.
Keep the following points in mind when writing the information in the records.
- Listen to what they say about their health and ask them what they need
to know.
- Look at things that are important for the health of the people, e.g., source
of water supply, condition of sanitation and housing. Are the structures
safe? Are they used properly or do these need to be improved?
- Check and count events or happenings so that you will know how many
these are; for e.g., if there are more than the usual number of Diarrhoea
cases in specific time.
Organize your activities with regard to record keeping.
Complete the records timely keeping in mind following points:
- Write them promptly
- Keep them up to date

Be accurate and complete to report the- essentials and details

Replace records at the appropriate place
Consult your supervisor in completing the record in case of any difficulty
Keep in mind the agency policies while maintaining the records.
 8.3.6 Filing of Records
Correct filing of records is essential. Correct and systematic filing saves time and
effort. Different methods are used for filing in different agencies. These include:

Alphabetical filing

' As per the geographical division

As per Index cards .

, You need to know which method/system is followed in your agency. However
some of theagencies may use a combination of these methods.

8.3.7 Points to Remember

- Records must be kept carefully and in clean conditions.

- Records should be carefully stored and not stolen.

- Records should be handled by authorized persons.

- Develop a good system of filing of the records.
- Maintain the confidentiality and secrecy of the records.

Record keeping can be a time consuming job, if you do not develop a system which
is feasible and easy to maintain. Record your daily activities when you finish your
day's work. This will not only make your record keeping easier, but will also
ensure that all information is included and there are less chances of forgetting. For
this reason you should spare sometime for completing the records.
Nursing Practices in
Community Health-I

Activity
1) Prepare a list of different types of records used and registers maintained in
your health centre.
Go through these records carefully and fill up each card and register.
Collect sample copies of the records and fill up the records.
Develop your own sample copy by incorporating changes.

2) Maintain records of two infants, preschooler and ante - natal mothers in the
health agency and check if you kept the guidelines in mind while recording the
information.

8.4 LET US SUM UP

Recorded facts have a value and scientific accuracy. They are more than the
impressions of memory. They serve guidelines for better administration of
community health services. The contributions that as community nurse and
other members of the health team make for delivery of care are reflected in the
records maintained. In this practical you have learnt the importance of records and
reports, types of records maintained in health center and the procedure of recording
information.

8.4 ANSWERS TO CHECK YOUR PROGRESS

1) Records help in collecting statistics that are important for the health
authorities. They help in planning health care services and assessing the
requirements like drugs and other equipments. Records provide legal
documents for community health action. Records evaluate the progress and
preplanning of the health programmes.

2) General information about the village, are, family folder, MCH records, Family
welfare records, vital events records such as registration of births and deaths,
record of medical care and referrals, Records of stock received and used
should be maintained.

3) Records must be legible and kept in clean conditions, it should be written

promptly and kept up to date. The sentences should be short and clear, the
records should be accurate and readily available. There should be a good
system of filing of the records and kept in proper place.

4) Different methods are used in filing of records. They are alphabetically,

numerically or as per geographical divisions.