NAME OF THE SUBJECTS : Nursing foundation

UNIT :
NAME OF THE TOPIC : Records and reports
PLACE : GNM 1st year class room
GROUP : GNM 1st year
DATE : 17/01/2020
TIME :20 MINUTES
SIZE OF THE GROUP : 60 Students
AV AIDS USED :
METHOD OF TEACHING : Lecture cum discussion method
NAME OF THE EVALUATOR :
NAME OF THE STUDENT TEACHER : Anusikta Panda
PREVIOUS KNOWLEDGE OF THE STUDENTS: Students have some knowledge regarding recording
and reporting
GENERAL OBJECTIVES : At the end of the class the students will able to-
Describe recording and reporting,Discriminate different method of recording and reporting,Identify different
types of recording and reporting
SL TIM SPECIFIC CONTENT TEACHING AV AIDS EVALUATIO
NO E OBJECTIV LEARNING N
E ACTIVITY
1 1min Self introduction
2 1min INTRODUCTION:
Reporting and recording are the major
communication techniques used by health
care providers.
3 ANNOUNCEMENT OF TOPIC:
RECORDS AND REPORTS
4 2min Define DEFINITION OF RECORD: Teacher defined LCD What is the
record and It is a written communication that permanently
record and report definition of
report documents information relevant to a client’s by using LCD. record?
health care management. It is a continuing
Students wrote
account of the client’s health care needs [ Sr.
Mary lucita ]  down the
definition on
DEFINITION OF REPORTS: their note.
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 ] 
5 Enlist the PURPOSES OF CLIENT’S RECORD CHART: Teacher enlisted the LCD, Black What are the
purposes of  Communication: Provides efficient and effective
purposes recording board purposes of
1min record and method of sharing information.method of sharing and reporting by record and
information. using LCD, students
reports reports?
 Legal Documentation: It is admissible as nodded their head
evidence in a court of law.in a court of law. and took the note
 Research: Provides valuable health-related data
for research.research.
 Statistics: Provides statistical information that
can be utilized for planning people’s future
needs.be utilized for planning people’s future
needs.
 Education: Serves as an educational tool for
students in health discipline.students in health
discipline.
  Audit & Quality: Monitors the quality of care
received by 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.entire health team uses to plan care for the
client.

PURPOSES OF REPORT:
 Report is an essential tool to 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
6 3min CHARATERISTICS OF A GOOD RECORD: Teacher elaborated Palmlet What is the
characteristics of meaning of
 Accuracy 
good record and
 Consciousness  accuracy?
 Thoroughness  report by lecture
 Up to date  cum discussion
 Organization  method and students
 Confidentiality  listened carefully.
 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.

7 3min METHOD OF RECORDING: Teacher explained LCD, Black What is the

the methods of board source oriented
 Narrative charting (traditional client record)
recording and
 Source oriented record: record?
 Problem focused charting: reporting students
 Problem-oriented medical record( pomr) listened carefully by
/nurse’s or narrative notes (soapie format) taking notes
 Apie(pie) chart:
 Charting by exception (cbe)
 Computerized documentation
 Case management process
METHOD OF REPORTING:
1. Written
2. Verbal
8 4min TYPES OF RECORDS: Teacher elaborated Flannel board What are the uses
the types of records of progress note?
1. Outpatient and inpatient records and reports by
2. Nurse’s recording showing flannel
3. Doctor’s order sheet board and students
4. Graphic chart of TPR focused on the av
5. Reports of laboratory examination
aid
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 

9 2min ADVANTAGESOF RECORDS AND Teacher explained Handouts What is the

REPORTS: the advantages and meaning of
 Monitoring operations disadvantages of
 Controlling
controlling?
recording and
 Guide decision reporting by using
 Employee motivation handouts
 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

10 1min NURSES RESPONSIBILITY IN RECORDING Teacher elaborated LCD,black board What can be the
AND REPORTING: nurses responsibility other
in recording and
 The records are kept under the safe custody of the responsibility of
reporting
nurse in each or department nurses?
 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.

11 1min 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.
12 1min 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.

ASSIGNMENT:
Write an assignment on different types of records and reports?
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