LESSON PLAN ON RECORDS & REPORTS

SUBJECT;- COMMUNITY HEALTH NURSING-1

TOPIC:- RECORDS & REPORTS

DATE:

PLACE: First year GNM classroom

DURATION: 1 hour

GROUP: 1st Year GNM

TEACHING METHOD: Lecture, Discussion and Demonstration

A.V AIDS: White board, PPT presentation

LANGUAGE: English.

NAME OF THE SPEAKER: MS VANDNA PATEL

GENERAL OBJECTIVES:

At the end of the topic the students will be able to gain knowledge about ,

∞ records and reports and its uses

∞ maintenance of records and reports

SPECIFIC OBJECTIVES:
on completion of class students,
∞ Define records
∞ Discuss types of recods
∞ Explain about principles & uses of writing records
∞ Define reports
∞ Discuss Types of reports
∞ Explain about maintainance of Records and reports
 TIME SPECIFIC CONTENT ACTIVITIES AV AIDS EVALUATION
OBJECTIVE TEACHER STUDENTS
05 MIN INTRODUCTION:- Lecture cum Listening & Whiteboard
discussion participating & PPT
Records and reports are the good tools of
communication in any organization to function
efficiently. Informations are transmitted from
downward to upward and from upward to downward.
Effective communication is vital to the client care
among the health professional. Nurses as a member of
the health care team communicate informations about
the client's condition through records and reports
among the health care providers. Client depends on
nurses to communicate about their health problems to
the doctors and other concerned with him for best
quality of care. It is essential for all the members of
health care team to have accurate practice of
maintaining records and reports.
02 MIN Define records DEFINITION:- Lecture cum Listening & Whiteboard What is records?
discussion participating
Records are the presentation of facts, figures, date
andother informations in writing. "A recomal
permanent written presentation of information.
In health care setting, a record is a clinical,
scientific, administrative and legal document tel the
nursing care given to the individual, family and
community. Records are practical and indispens tools
of the doctors, nurses and other paramedical staff to
plan and deliver the best possible care aportanAdm
Trea Labeis the a client.
05 MIN Discuss types of TYPES OF RECORDS:- Lecture cum Listening & Whiteboard Which are the
recods discussion participating & PPT types of records?
Records are broadly divided into four categories: 1.
Periodical records: These are of two types:
(1) Temporary records: These are casual or daily
records. (ii) Permanent records: These are cumulative
 or continuing records. These are the stid Mew health
records, once made and carried out to the next standard
about health information the students like
immunization, weight, height and other health check-
up every year on Cem same card. It is possible to
review the total history of the child/individual and
evalum Dieprogress over a long period.
Similarly nursing students cumulative records
regarding their learning experience are a Bim on the
same record as and when they learn.

2. Unit based records: It includes:

Individual records includes individual health card.

Family record of family folder

Community records-records of health problems of the

community National Health Program Records.

3. Subject based records:

Medical and nursing records pertaining to the treatment

and medicine records.Economical records-financial
structure of family and village Social records-records
of social structure Political records.

4. Collection place based record:

Collected at institutions, i.e. Records of hospitals and
health centers. Records to be kept with individuals, e.g.
Immunization card, disease card.
20 MIN Explain about PRINCIPLES OF WRITING RECORDS:- Lecture cum Listening & Whiteboard What are the
principles & uses of discussion participating & PPT principles and
writing records ∞ Records should be written immediately, after an uses of records?
event has occurred. Records should be real based on
facts, observation, conversation and action.
∞ Only accepted abbreviation should be used.
∞ Short and clear sentence to be used. Records should
be appropriate, accurate and legible.
∞ Records are valuable legal documents so it should be
kept confidential. Records should be written with blue
ball point ink.
∞ Uniformity in writing records should be maintained.

USES OF RECORDS :-

For Staff Nurses/Community Health Nurses:-

∞ Help to plan and implement care to the client.

∞ Help to evaluate the care and teaching given to the
client. Prevent duplication of work.
∞ Help to assess the quality and quantity of care given.
Protect in case of legal issues.
∞ Serves as a guide to the professional growth. Help in
auditing the nursing care.

For Doctors:-
∞ Guide for diagnosis, treatment and follow-up care.
Help in evaluating the services provided.
Indicate the progress of the patient and continuity of
care.
∞ Useful for doctors in making research and in medical
practice.

For Health Agency:-

∞ Records are the proof of services provided by each
worker.
∞ Help in auditing the care provided to clients. Help
the administration in assessing the performance of their
own institution.
∞Used as an evaluation tool during conferences and
meeting.
∞ Provides justification of expenditure of funds. Assist
in finding out, health problems of community unit.
∞Legal document for community health activities.
∞Assist in determining the need of resources like
 medicine, equipment and manpower. Means of
communications between health workers, family and
community.

For Individuals:-
∞ Helps to make them aware of their health needs.
Serves as a guide for future treatment and care.
03 MIN Define reports DEFINITION:- Lecture cum Listening & Whiteboard What is reports?
discussion participating
REPORTS

Reports are the verbal or written information shared

between the health workers. Reports summa the
activities and services of nurses and health care
workers.
05 MIN Discuss Types of TYPES OF REPORTS:- Lecture cum Listening & Whiteboard Which are the
reports discussion participating & PPT types of reports?
Verbal report and Written report

Verbal Report:-

Verbal reports are more convenient when the

informations are for immediate use. Sometimes
emergency verbal reports are followed by written
reports later on, e.g. Nurse in charge of patient ca
reports about the condition of patient to the treating
physician telephonically and taking instructio about
patient care. Later on she puts in writing. Similarly
while changing shifts, nurses handover with verbal
reports along with written reports. Verbal reports are
also made about certain complaints for mediate
rectification, e.g. about emergency equipment, etc. or
some unusual incident happened nd immediately
reported to the concerned authorities, verbally and later
on in writing

Types Of Verbal Reports:-

Report between head nurse and staff nurse during
round of head nurse. Report between the members of
health team.
Reports on accident, mistakes and complaints while
changing the shift. Report between student nurses and
clinical instructor.

Advantages
Helps to deal with emergency when time is premium.
Helps in implementing proper care of patients on
verbal instructions.

Provides feedback,

Saves time, build-up confidence and maintain good

interpersonal relations professionals.
Serves as a primary source of information.

Disadvantages
Possibility of mistakes due to wrong interpretation.
No proof, personnel can deny what is told.
No permanent record is present.
Can result in legal problems. Not useful in legal
matters.

Written Reports:-

Reports are written when the information has to be

used by several persons which is of permaner value.
Examples of written report are:

Day and night reports

Census
Interdepartmental reports
Weekly reports
Monthly reports
Special reports on Accident reports
Evaluation reports
 Transfer reports
Legal reports.
USES OF REPORTS:-

Reports give information about the condition of the

patients and day to day progress of patient health.
Reports are used as an aid in planning patient care. In
community, reports help in studying the health
problems of an area so that an appropriate action can
be taken to solve.
Used in health planning.
Shows the kind and amount of services rendered in a
community.
15 MIN Explain about MAINTENANCE OF RECORDS AND REPORTS: Lecture cum Listening & Whiteboard How to maintain
maintainance of discussion participating & PPT the records and
Records and reports Since the records and reports have legal reports ?
implications. It is the duty maintaining the records and
reports to keep them, under safe custody. f the nurse in
charge of There should be no room left for leakage of
information contained in the records and reports
Nurse should maintain records and reports immediately
after the incident
Written records and reports should be preserved in a
chronological order so that it is easily available when
required.
Records and reports should be handled carefully to
avoid destruction. Records and reports should be
protected from mice, termites, and insects, etc.
Records related to medico-legal cases, dying
declaration and will, etc. should be handled carefully
for giving witness wherever required.
People get facilities and legal protection on the basis of
records. In such cases only with the written permission
of authorized person, the Xerox copy of the records can
be given and entered in the
register. Records should be made accurate and there
should be no mistake.
 Medico-legal cases records and reports should be kept
under lock and key. For the destruction of absolute
records, legally accepted method should be used.
05 MIN SUMMARY:- Lecture cum Listening & PPT
discussion participating
Records and reports are necessary to collect
useful informations for assessing the health problems
and health needs of the individuals, families and
community. The records kept at subcenter levels are
vital event records, eligible couple record, family
folder, MCH care record, family welfare records. The
records should be written promptly after providing
services. Records should be clear, eligibie, accurate,
complete and written with blue ball point ink. Reports
are summarized services either written or verbal
Records have legal values so it should be kept under
lock and key. No unauthorized person should have
access to the records and reports. Nurses are
responsible for maintaining records and reports in the
hospitals as well as in community settings.

BIBLIOGRAPHY:-

BT Basavanthappa,nursing foundation fo koob txeT

srehsilbup lacidem srehtorb eepyaJ yb dehsilbup"(p)
LTD page no:
CP Baveja, " gnisrun rof ygoloiborcim fo koob txeT
"5th edition2005 publised by arya publishing company
page no:
potter and perry,s,of nursing latnemadnuf fo koob
txeT" published by elsevier page no:483 Rajendra
prasad seervi abhishek soni " Text book of nursing
foundation. lacidem srehtorb eepyaj yb dehsilbup
"publishers.no page:
Sr.Nancy, FO ECITCARP DNA SELPICNIRP "
NURSING" VOL. 1published by N.R. Publishiung
house page no:
Valsamma joseph and susmma varghese, gnisrun
publications frontline foundations" published by. page