PRACTICAL 4 RECORDS AND

REPORTS
Structure

4.0 Objectives

4.1 Introduction

4.2 Records and Reports in Nursing Service Administration

4.2.1 Meaning of Record
4.2.2 Purposes of Nursing Records
4.2.3 Types of Records
4.2.4 Reporting

4.2.5 Factors to be Kept in Mind while Reporting and Recording

4.3 Student .Records and Reports

4.3.1 Introduction
4.3.2 Purposes and Uses of Records
4.3.3 Types of School Records

4.4 Let Us Sum Up

4.5 Key Words

4.6 Answers to Check Your Progress

4.7 Activities

4.0 OBJECTIVES
After going through this practical, you should be able to:

• define records and reports maintained by nursing personnel in the hospital and
school of nursing;

• enlist the various records maintained;

• describe the purposes of records and reports; and

• apply this knowledge while maintaining records and reports in the hospital and
school of nursing.

4.1 INTRODUCTION
The principles of administration are described as 'POSDCORB'. The 'R' stands
for recording and reporting. Recording and reporting is related to all other parts of
the administrative process. It is a secondary function because it supports planning,
organizing, staffing, directing, and controlling and boarding. It is intetrwoven with
them all.

Every organization keeps some kind of records. Every department in the hospital
has its own records. Similarly nursing service section and school of nursing maintain
various records. In this practical we shall learn the various records maintained by
nurses in the hospital and school of nursing. The examples of few of the nursing
records will also be discussed.
Administration of
Nursing Services HOW TO STUDY THIS PRACTICAL
and Education
This practical deals with the study of various records and reports in nursing
service administration and school of nursing.

As you read through this practical you will find that administrative records and
reports are of various types and very significant from patient care point of view.
This practical will also deal with the' records and reports of students. Hence the
practical will be discussed under two headings:

• Records and Reports of Nursing Service Administration.

• Records and Reports of in School of Nursing.

SKILLS TO LEARN FROM THIS PRACTICAL

• For reading this practical, you should review your knowledge on records and
reports in other subjects.

• Review the advantages of making various records.

4.2 RECORDS AND REPORTS IN NURSING

SERVICE ADMINISTRATION
You must have read about records and reports in various other courses. In this
section basically we shall be discussing records maintained in the hospital by nursing
personnel.

4.2.1 Meaning of Record

The dictionary meaning of record is a written report of any fact or facts, or to put a
matter down in writing so that it may be read or referred afterwards whereas
reporting is giving account of something, telling about something.

Record is a document of facts which contains statements by nursing personnel of

conditions found in the patient, nursing needs identified, care planned, implemented
and evaluated. Records of various kinds are maintained by the nursing personnel
which improves the patient care directly or indirectly.

4.2.2 Purposes of Nursing Records

The nursing records are important for the stand point of patients, nurses and the
hospital, for nursing education and research.

1) In Terms of Patient Care

• Records are maintained to improve the patient care.

• Records are essential to make immediate nursing diagnosis and nursing

interventions. For example if patient's pulse is low, BP 90/60 mm of Hg,
respiration shallow, recorded by the nurse looking after the patient. A senior
nurse puts the patient on oxygen and informs the doctor immediately.

• It serves to avoid ommission or unnecessary duplication of patients care.

• It serves as an evidence in the event. if legal questions mise.

• Record would enable the patient to claim for insurance or contributory health
schemes.
2) In Terms of Nurses Records and Reports

The nursing records serve as:

• Assurance of quality, quantity ofnursing care being provided.

• Records help in continuity of nursing care.

• Provides legal protection to the nurse.

• Records serve as an important pre-requisite for evaluation of nursing care.

• Records help in research and continuing education of nursing professionals.

Recorded observation of patient care provides the basis for clinical research.

3) In Terms of Nursing Administration

• The nursing administrative records are essential to document the type and
quantity of work assigned and accomplished.

• Nursing administrative records furnish proof of the type and quality of care
rendered to patients. For example the record shows that patients have been
discharged without having any bed sores.

• Records also provide evidence of efficiency of individual nurse for

administrative and clinical purposes ..

(For any type of promotion or posting in a particular clinical area).

• Records strengthen the nursing administrator in event legal questions arises.

• They serve as an administrative record of personnel performance and staffing

needs, for budget preparation and justification, for physical facilities, allocation
and utilization, for statistical data for administrative use and evaluation, for
estimating equipment and supplies utilisation and needs.

4.2.3 Types of Records

1) Patient's Clinical Records.

2) Nursing Administrative Records.

I) Patientis Clinical Records

The patients clinical chart is the record which the nursing sister or assistant nursing
is most concerned. The common patient records are:

• Admission history

• Vital signs/Symptoms cltart

• TreatmentlMedicational sheet

• Intake/Output chart

•. Nursing care plan and -progress report of the patient.

By now you have already learnt about the nursing care plan and progress notes. Let
us take an example of comprehensive nurses notes. The nurses notes should be
written daily in every shift. The following sample will help us to develop nurses
notes.
37
Administration of Sample of Nurseis Progress Notes
Nursing Services
and Education Name of the Patient Mr. Ram Singh
Age 45 years
Sex Male
Address Flat No.1 0, Badli, Delhi
Ward No. 11

Bed No. 20
MRDlHospital Admission No. 6123985
Date of Admission IOth July, 1994
Diagnosis Pain in abdomen

Day! Time Treatment TPR Diet Urine Bowel Remarks

Date

Monday
10.7.94 6AM Tab. Lasix 6 AM Bed tea Passed Bowel not Patient slept
98.4
0
given at Twice opened well at night.
80-16 6.30 AM expressed got up twice
that he is for a glass of
expelling water
gas

Rx Tab. Belladonal T 9AM Looks fresh

8 AM Took Had bowel and alert.
two movement T.P.R. is
slices normal
of bread
10 AM Inj. 300 ml Patient at Patient
Crystalline of milk 10 AM complained of
Pencilline and 10 gm experssed pain at 9.30
10 lacs. butt~r that he had AM after .
normal taking food
motion B.P. was 100/
70mm of Hg.
Patient looked
restless.
Doctor on duty
informed.
Back massage
given. Patient
felt comfortable.

Likewise a plan should be developed for the assigned duty hours and before handing
over to the evening nurse. The morning nurse must put her initials and hospital
number. After writing the nurses notes for 24 hours a fresh sheet may be started for
the next day.
TreatmentlMedication Card
A Kardex may be developed to write the total treatment of the patient. Each patient
will have an independent card. A kardex may be 6" x 4" size.

Name of the Patient Shano

Age 40 years
Bed No. 20
Ward No. 12
Date of Admission 19.9.2006
38 Diagnosis Cholecystitis
 Records and Reports
Treatment Dose Frequency - Times

Medication
Capsule FasoVit T 0.0. 8.00 AM
Cap. Ampicillin 500mg 010 10-4-10-4

Injections

Inj. B. Complex 2 cc 0.0. 10.00AM

on AID.

Special Instruction
Fat free diet
1500 calories diet
Maintain 1/0 chart

Sample of an Intake/Output Chart

Most of the patient's fluid and electrolyte balance gets disturbed due to illness. It is
mportant to maintain their accurate record of intake and output.
Name of the Patient
Bed No.
Ward No.
Date of Admission ........................................ MRD No .

Diagnosis

Day & Date Intake

Time Oral Ryles IIV Any
~ Tube Other
Feed

Wednesday 8AM --- 6AM

9.7.94 Water Glucose 5%
100 500 rnl,

9AM 11 AM
Tea Normal
50 ml Saline
500 ml.

Output

Urine Stool Vomiting Any Nurse's Remarks

Other

7 AM Two 8AM 9.00 AM T.P.R. recorded

600 ml stool Vomitted Temp. 100° F Pulse 110
consistency once Res. 24 BP 120/80 mmg.
Hg.
thin, water .- Patient looks weak was
Iike restless for sometime.
- IN is on flow
- Observation is being
made every one hour of
vital signs.

The total intake and output is written on the next day's intake output chart to identify
the deficit of any kind.
39 .
Administration of 2) Nursing Administrative Records
Nursing Services
and Education These records can be maintained at the unit level and submitted to the Nursing
Superintendent. The records can be:

• Number of nurses on roll in the unit and rotation plan duty roster.

• Stock register of the unit for medicine, equipment and supplies.

• Annual confidential reports of the staff nur es,

• Record of staff development programme including orientation and inservice

education programme.

• Records of performance of staff members.

Nursing Superintendent has to keep certain records readily available:

• Philosophy, aims and objectives of the hospital.

• Policies of the hospital for recruitment/selection and other area.

• Total number of nurses on the roll.

• The physical layout of various departments.

• Confidential record of the nursing personnel.

• Staff development records.

• Record of the meritorious work, performed by the nursing personnel.

• Any disciplinary action record.

• Record of various committees and meeting, memorandum, notices etc.

4.2.4 Reporting
Reproting consists of written and verbal communication between and amongst
persons associated with nursing whereas RECORDING consists of preserving such
communication either in writing or preserving on various electronic media.

1) Change of Shift Reports

Change of shift report is the oldest report in the nursing service and it still is very
important. Though it has gone through many changes but it still remains essentially a
method of transmitting the information about care of patient from one set of workers
to another.

Reports provide the staff an opportunity to learn salient points about patients that
have occurred during the hours of prior to their taking the responsibility of patient
care.

There are many formats for such overall reporting. Essential information such as
discharge, transfers and admission, immediate pre and post operating patients,
critical patients, those receiving important procedures such as blood transfusion,
those with complication factors such as bed sores/decubitus ulcers, isolation,
neurotic states, or untoward incidents and VIPs.

Format also provides staffing information such as number of patients of each

category, i.e. ICD. Acutely ill, evening and night shift nursing managers require the
same type of infomation.
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2) General Periodic Reports Records and Reports

Though these general periodic reports are not as common as change of shift, but
they are often used. .

For example the Nursing Superintendent is accountable to the hospital

administrator. Likewise the nursing service director requires similar accountability
in the form of written report from the department heads or supervisor who in turn
gets it from the head nurses. Head nurses get this written report from the staff
nurses.

These are specialized reports which help in preparing these generalized reports
such as summary of nursing hours, distribution and kinds of works etc.

3) Hospital Annual Reports

A detailed report of the nursing services is included in the hospital annual report.

Though it may not be existing so significantly in our country but regulatory or

accrediting agency reports are equally important. This body gives the report
whether the hospital and nursing section is following the minimum norms to give
effective patient care.

4.2.5 Factors to be Kept in Mind while Reporting and Recording

a) Accuracy of the records is very significant.

b) Accuracy of records and report is affected from honesty, precision and

clarity.

c) Records and reports should have sufficient details but not too extensive to
loose the actual point.

d) Objectivity of records is equally important. For example checking of certain

facts and then writing the report will have more objectivity.

e) Timeliness and promptness helps in better records and reports. For example a
statistical information of infection from OT is causing delay in post-operative
recovery will lead to promote action for fumigation of the OT.

f) Maintaining the confidentiality of records and report helps in protecting

human rights as nurses have a very important role to play in maintaining the
records.

g) Availability of record should be to the patient only in consultation with the

doctors.

Activity 1
i) List the types of records being maintained in your ward/hospital.

ii) Develop nurses notes for one of your patient's whom you are nursing during
your posting (Follow the format given in the text).

Check Your Progress 1

1) Define the terms recording and reporting.

41
.Administration of
2) Given below are some of the statements, encircle 'T' if you find the statement
Nursing Services
and Education is 'True' and 'F' if the statement is 'False':
a) Records and reports are maintained to improve the patient
care only. (TIF)

b) Records are maintained to avoid duplication of patient care. (TIF)

c) Adequacy and quality of nursing care can be assessed from

records. (TIF)

d) Nursing records hold no significance in legal events. (TIP)

e) Nurses do not have much role to play in maintenance of
records. (TIF)

4.3 STUDENT RECORDS AND REPORTS

The other important types of records and reports are for the School of Nursing.

4.3.1 Introduction
Records have an important role in a nursing education programme. Undoubtedly
they are necessary for day-to-day administration of the school of nnrsing, records
provide continuity from the time the school was established. Those teachers who
maintain good records are good at counselling the students.

4.3.2 Purposes and Uses of Records

• I Students records are used for counselling. For example a student who had
been performing very well has been deteriorating.in her performance which
the records are showing she can be called to identify her problem through
counselling.
• For service to former students or alumni. In case, they need any information,
records would help.
• Records provides basis tor institutional planning. The expansion of the
programmes.
• Records serve as a tool to evaluate a school of nursing programme.
• School of nursing records can be used for legal purpose if required.
• Records provide data tor research and other investigation, if needed.
• Records can help in fomlulating report of various issues, like report about the
type of result of students of a school of nursing for last 10 years.

4.3.3 Types of School Records

i) School/Students Records.
ii) Faculty/Staff Records.
iii) General Records.
i) School/Students Records
Students record should include:
a) application from- and report, selection and admission of students.
b) students attendance records in classrooms, community and clinical fields.
c) record of each students progress report/exmnination marks internal
assessment records.
d) record of each students clinical experience. c

e) health records of each student.

42 f) cummulative record - a sample of which is given below:
 SAMPLE OF CUMMULATIVE RECORD Records and Reports

SCHOOL OF NURSING

CUMMULATIVE RECORD PERFORMA FOR G.N.M. NURSING

STUDENTS

THREE YEAR COURSE

Photograph
Passport Size

I) Code No .

Name (IN BLOCK LETTERS) .

Marital Status . Enrolment No .

Date of Birth . Roll No .

Place of Birth . Maidan Name .

Religion : . Identification Mark .

Nationality .

Father's/Husband Name . Father's/Husband's Occupation .

Permanent Address . Address of Gaurdian or Next of kin.

GaurdianlNext of kin .

Relationship with the candidate: .

11) Previous Academic Record

General Education:

Name of the Division % SUbjects

Board/University

Any other qualification:

Date of Admission to the Course Date of Completion .

Academic Achievement:
Year Paper Subject Hours Quali- Internal Marks Total Remarks
Theory fying Assess- obtained Marks
Practical marks ment

1st Year Special

Achievement

2nd Year Merit

Scholarship

3rd Year Co-curricular

Activities

Grand Total:
43
Administration of 75% and above = First Class
Nursing Services
and Education 60% -74% = Second Class
50% to 59% Third Class

Ill) Health Records

History of any previous illness:
On addrnision: at the end of 1st Year 2nd Year 3rd Year
Height.

Weight:
Primary vaccination:
TABC
Hepatitis B:
State of Health:
State of Health on completing course:
Any other marks :
Summary
Personal Characters Attitude
Honesty
Punctuality
Responsibility
Accountability

• Toward correction
• Toward improvement
• Further study
Cooperativeness
Ability to Nurse
Ability to communicate
Resourcefulness
I.P.R. Teacher
Classmates
Parents.

2) Faculty Records

Copy of the letter of appointment.

Job description and workload.

Record of faculty members and their educational qualification, previous
experience, any short-term courses attended. membership in professional
activities, publication, holding office in association or organization,
participation in conferences and semillars.

Periodic evaluation or progress report.

44 Leave record and/or health record.

3) General School Records Records and Reports

Philosophy, aims and objectives of school of nursing.

Written policies of the school in various areas i.e. Library, Mess,

Discipline, Visiting Time, Ward Duty, Class Hours, Hostel, etc.

Budget proposal and allotment to various departments.

Copy of correspondence letters with agencies where the visits are

arranged.

Copy of school of nursing prospectus.

Inventories of stock, etc.

Reports and records of various committees.

Admission Records of student.

INC Reports.

State Nursing Counsel Reports.

Records of important Landmarks of the School.

Governing Body Meeting Proceedings while Governing Body exists.

4) Reports of School of Nursing

Reports are detailed worked out facts about the school. The number and nature of
reports will depened upon the controlling body and nursing councils.

The informations which are commonly included in the annual report are:

History of the school nursing.

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

administration and curriculum.

Any change in the school programme than of the previous report.

Proposal of plans for future development.

Problems faced by school of nursing.

Recommendation, if needed.

Activity 2
i) List some of the common records maintained in your school of nursing where
you were student or teacher.

ii) Write the various aspects of annual report which was read on your lamplighting
ceremony in your school of nursing/hospital.

Check Your Progress 2

1) List five purposes of records maintained in a school of nursing.

45
Administration of
2) Given below are some of the records. Classify them under the following
Nursing Services
and Education headings:

Students Records Faculty Records General School Records

Progress report of students

Any short term course attended

Holding office in professional association

Clinical experience

Leave

Health

Written policies of the school

Budget proposal.

4.4 LET US SUM UP

Though you have read various kinds of records and reports, but this practical
describes the nursing services and school of nursing records in detail. Example
given on nurses notes, kardex and intake/output charts would enable you to practice
these in the clinical setting. School of nursing records explained would help you
while working with students in wards and schools of nursing.

4.5 KEY WORDS

Accrediting Agency : The agency which helps in giving licence to the school of
nursing or hospital. For example, INC is the accrediting
body for schools of nursing in India.

Precision Exact, clear in meaning or particulars. .

Preserving Keeping Safe.

Prior Earlier or Former.

Salient Chief or Standing Out.

Transmitting To send an information to another person or place.

4.6 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

1) Reporting consists of written and verbal communication between and amongst

persons associated with nursing whereas recording consists of presenting such
communication either in writing or presenting on various electronic media.

2) a) F

b) T

c) T

d) F

e) F

46
Check Your Progress 2 Records and Reports

1) a) Records are used for counselling the students.

b) Providing reference services to former students and alumni.

c) Records serve as a tool to evaluate a school of nursing programme.

d) Records can be used for legal purposes, if required.

e) Records provide for planning of curriculum and institution.

2) Student Records Faculty Records General School

Records

• Progress Report
of students
• Any short-term
attended
course • Written Policies of
school of nursing

• Clinical experience
• Professional
Holding Office in • Budget Proposal

• Health
Association

• Leave
• Leave
• Health
4.7 ACTIVITIES
i) List the types of records being maintained in your ward/hospital.

'ii) Develop nurses notes for one of your patient's whom you are nursing during
your posting (Follow the format given in the text).

iii) List some of the common records maintained in your school of nursing where
you were student or teacher.

iv) Write the various aspects of annual report which was read on your
lamplighting ceremony in your school of nursing/hospital.

47