V.

RECORDS IN FAMILY HEALTH NURSING

Objectives:
o Document client’s responses/nursing care services rendered and processes/outcomes of the
nurse client working relationship.
o Ensure completeness, integrity, safety, accessibility and security of information.
o Adhere to protocol and principles of confidentiality in safekeeping and releasing records and
other information.

Records are necessary for the continuation of delivery of family health care services and its
evaluation while evaluation of family health services is necessary to identify the new and continuing
family health needs.
Family records include information based on factual events, observation results or measurements
taken such as height, weight, body circumference or laboratory examinations carried out like
hemoglobin, urine test, stool test and sputum examination depending upon the problem of the family.
These also include records of immunization, nutritional status, medical prescription and curative
procedures carried out. Demographic data and individual personal history are also included in the family
folders.
Health records refer to forms on which information about an individual and family is noted.
Information varies from socio-economic, psychological, environmental factors, etc. Records are practical
and indispensable aid to the doctor, nurse and other health care workers in giving best service to
individual, family or community. Recorded facts have value and scientific accuracy and are guidelines for
better administration of family health services. Contributions of health team members are reflected in
case records. Records are also means of communication between a health worker and the families.

A. Importance and Uses

 Provides documentation of services that have been rendered and supply data for program
planning.
 Provide the practitioner with data required for application of professional services for
improvement of family’s health.
 Records are tools of communication.
 Effective health record shows health problem in the family and other factors that affect health-
standardized sheet/form.
 Records indicate a plan for future.
 Provides baseline data to estimate long- term changes related to services.
 Provides opportunity for providing evaluation of the situation.

B. Types of Records and Reports

FIELD HEALTH SERVICES AND INFORMATION SYSTEM (FHSIS) (Cuevas, 2007)

Objectives
 To provide summary of data on health services delivery and selected program accomplished
indicators at the barangay, municipality/city, district, provincial, regional and national levels.
 To provide data which when combined with data from other sources, can be used for program
monitoring and evaluation purposes.
 To provide a standardized, facility level data base which can be accessed for a more in-depth
studies.
 To ensure that the data reported to the FHSIS are useful and accurate and are disseminated in
a timely and easy to use fashion.
 To minimize the recording and reporting burden at the service delivery level in order to allow
more time for patient care and promotive activities.
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Components
 Family Treatment Record
- Treatment Record is the fundamental building block or foundation of the FHSIS. This is
the document, form or pieces of paper upon which the presenting symptoms or
complaints of the patient on consultation and the diagnosis (if available), treatment and
date of treatment is recorded.
 Target Client List
- Target/Client Lists constitute the second building block of the FHSIS and are intended to
serve four purposes:
1. To plan and carry out patient care and service delivery.
2. To facilitate the monitoring and supervision of services.
3. To report services delivered.
4. To provide a clinic-level data base which can be accessed for further studies.
 Reporting Forms
- Tally/Reporting Forms constitute the only mechanism through which data are routinely
transmitted from one facility to another.
 Output Reports
- Output Reports or Tables are useful for monitoring/management purposes at each level
of DOH management.

Reference for RECORDS IN FAMILY HEALTH NURSING

Cuevas, F. P. (2007). Public health nursing in the Philippines. Philippines.