LESSION PLAN

ON

RECORDS AND REPORTS

Mr. MD. Danish Rizvi
M.sc nursing
Community health nursing (HOD)
Suruchi institute of nursing

SUBMISSION ON –
GENERAL INFORMATION:

Name of the teacher: Mr. MD. Danish Rizvi

Subject: Community Health Nursing

Topic: Records And Reports

Class:

Date:

Duration: 45 minutes

Methods of teaching: Lecture Cum Discussion

AV Aids: PPT, hand out, black board.

Place: Language: Hindi, English.

Previous knowledge of group: Previously Students was having little knowledge about the topic that is on Records And Reports.
GENERAL OBJECTIVES:

After the completion of the planned teaching program, B.sc nursing 2 nd year students will be able to gain knowledge about ‘Records And
Reports’ and they can apply their knowledge by on clinical and community area.
SPECIFIC OBJECTIVES: After the completion of the planned teaching program, the B.sc nursing 2nd year students will be able to :-

o To introduce the topic about the Records and Reports.

o To define the Records and Reports.
o To enlist purpose Records and Reports.
o To list out the Tips to maintain Records and Reports.
o To enlist types of Records and Reports.
o To describe the principles of Records and Reports.

S.NO TIME SPECIFIC CONTENT TEACHING LEARNING AV EVALUATION

OBJECTIVE OBJECTIVE AIDS
To Introduce The INTRODUCTION
1min Topic About
1. Records And Modern Community Depends
Reports. Much Upon Records. The Very
Existence Of Modern
Business, Modern Government
And Other Social Institutions
Depend Upon Records. In A
Modern Business, Contracts,
Letters, Invoices, Cheques,
Vouchers, Statistics, Pricelists,
Catalogues, Cost Analysis
Statements, Personnel Reports
And Tax Records Are To Be
Preserved And It Is Possible
To Do So Only If There Is
Proper Record Keeping And
Its Management.

Good Health Care

Administration Depends Upon
The Good Reports And
Records. Records And Reports
Are Good Tool Or Vehicle For
Transmitting Information From
Downward To Upward And
Upward To Downward
Communication. As A Result
Of Other Different Jobs And
Ranks In Organization Persons
Have To Play Different Roles
That Also Affect Their
Communication. Nurses As
Members Of The Health Care
 Must Communicate
Information About Clients
Accurately And Completely
And In The Mo St Timely And
Effectively Ways As Possible.

2. 1min To List Out The Purposes Of Record And Reports

Purposes Of
Records And 1. Assessing The Health Of The Lecture Cum Discussion PPT What Is The
Reports Community Purpose Of
2. Collecting Statistics, Which Are Records And
Very Important To Health Reports?
 Authorities.
3. Attention Of The Doctor Or
Other Members Of The Health
Team To Specific Needs Of
Individuals Or Families And For
Follow Up Services.
4. Information Of Supervisors In
Assessing Work Done.
5. Assessing Need For Various
Drugs, Transport Etc., Based On
Numbers And Types Of Patients.
6. A Tool For Health Education Of
Individuals, Families And
Communities.
7. Evaluating Progress Of The
Health Programmes For
Replacing.
1min Lecture Cum Discussion PPT
To Enlist The
3.
Maintain The Records To Be Maintained In The How to maintain
Records In Sub- Sub-Centre Include records in sub-
Center 1. Village Records, With General center?
Information About Each Village.
2. Family Folder And Individual
Health Cards.
3. Eligible Couple Register And
Record Of Contraceptives
Distributed.
4. Maternal And Child Health
Records (Including Antenatal
Care, Child Care, Nutrition And
Immunizations).
5. Records Of Distribution Of Iron
 And Folic Acid And Vitamin A
Solution. Vital Events Register
(Births And Deaths).
6. Stock Register For Receipt, Issue
And Balance Of Drugs.
Contraceptives, Stationery Etc.
7. Records Of Medical Care And
Referrals.
8. Inventory Of Furniture. Linen
And Equipment.
9. Records Of Meetings With
Village Health Guides And Dais,
Co-Workers And Supervisors.
10. Monthly Reports And Other
Periodic Reports As And When
2min Required. Lecture Cum HAND
To List Out The 11. Daily Dairy. Discussion OUT How to maintain
4. Tips To Maintain the records?
12. Maps, Charts, Graphs.
Records

Tips To Maintain Records

1. Records Must Be Kept Carefully And
In Clean Conditions, Safe From Rats
And Insects.
2. It Is Important That Records Are Not
Lost Or Mislaid. They Are Confidential
And Should Be Shown Only To
Authorized Persons.
3. Have A Good System Of Filing
Family Folders, Including Records Of
Individuals. Should Be Divided Into
Localities And Filed In Order Of House
 Numbers. It Is Useful To Have A PPT How to write the
5min Register Or Index Cards Tiled In Lecture records and reports
To Enlist Tips To Alphabetical Order Of The Heads Of
5. Write The Records The Families.
And Reports 4. Records Must Be Readily Available
And Kept Up-To-Date.

Tips T0 Write Records And Reports

The Delivery Of Health Services Is Not
Complete Until Details Are Written Up
In The Correct Register Or Record. The
Last Half An Hour Of Each Day's Work
Should Be Reserved For Completing
The Records.
1. Write Them Promptly And Keep
Them Up To Date.
2. Write Legibly, To Be Understood By
Others.
3. Keep Sentences Short And Clear.
4. Be Accurate And Complete In
Important Details.
5. Replace Records In Their Proper
Place.
6. Consult Your Supervisor In Case Of
Difficulty In Completing Records And
Wring Reports.

Monthly Report:
At The Beginning Of Each Month The
 Health Worker Has To Complete The
Report Forms And Submit One Copy To
Her Supervisor Keeping One Copy In
Her File At The Sub Centre. The Report
Includes Detailed Information Of Work
Carried Out By Herself, Village Health
Guides And Dais During The Previous
Month, Under The Following Readings,
 Immunization.
 Communicable Diseases.
 Vital Events.
 Family Planning.
 Maternal And Child Health
(Including Deliveries, Care
Of The Under-Five And
Nutrition Supplements
5min Supplied). Lecture PPT
To Describe About  Environmental Sanitation. What Is Records?
Records.  Treatment Of Minor
6. Elements (Patient Numbers,
And Referrals).
 Health Education Activities.
 Home Visits.
 Other Activities.

RECORDS
All Professional Personnel Need To Be
Accountable For The Performance Of
Their Duties To The Public. Since
 Nursing Has Been Considered As
Profession, Nurses Need To Record
Their Work On Completion.

Meaning
A Record Is A Permanent Written That
Documents Information Relevant To A
Client's Health Care Management.
A Record Is A Clinical, Scientific,
Administrative And Legal Document
5 Min Relating To The Service Provided. The Hand out
To List Out Of Records Are A Practical And Lecture How many
Purposes Records Indispensable Aid To The Doctors, purpose in
7. Nurses And Paramedical Personnel In recording?
Giving The Best Possible Service To
Their Clients. Recorded Facts Have A
Value And Scientific Accuracy For
More Than Mere Impression Of
Memory And There Are Guidelines For
Better Administration Of Health
Services. Records Are The Means Of
Communication Between Different
People.
Purposes
1. Records Provide Data For Programme
Planning And Evaluation.
2. Records Are The Tool Of
Communication And Dissemination Of
Information Between Different Teams
And Departments Of An Organization.
 3.Records Provide Plans For The Future.
4. Records Provide Baseline Data To
Estimate The Long Term Changes
Related To Services.
5.  Records Help To Detect Problems.
6. Records Provide An Opportunity For
Evaluating The Services.
7. Records Help In The Research For
5 Min Improvement Of Nursing Care. 8. PPT
Records Help To Meet Legal Lecture Cum Discussion
List out the Requirements And Thus Protect The
8. principle of Workers.
recording 9. Records Help In Nursing Audits. 10. How many
Records Help In Providing High principle of
Standard Of Service. recording?
11. Records Help In Continuity Of
Service.
12. Records Enable The Person To
Justify His / Her Actions.

Principles Of Recording
1. Clearly Identify The Client/ Student
By Name And Identification Number Or
Date Of Birth On Each Page Of The
Record. Each Side Of The Page Should
Be Numbered.
2. Record Each Patient/Client Contact-
 Either Direct Or Indirect
3. Be Factual, Consistent And Accurate.
4. Be Written As Soon As Possible After
An Event Has Occurred, Providing
Occurred (Contemporaneous)
Information
5 Be Consecutive.
6. Be Written Clearly And Legibly And
In Such A Manner That The Text
Cannot Be Erased,
7. Have The Date Of Contact Recorded.
8. Have The Time Of Contact Recorded.
9. Be Signed, With The Signature
Printed Alongside Each Entry, Together
With Professional Status. The Use Of A
Signature Register, Which Matches The
Signature With The Full Name And
5min
Professional Designation, Is Also PPT
Enlist The Types Acceptable. Which record used
Of Records. 10. Be Written In Black Ink. in hospital?
11. Ensure That Any Alterations Or
Additions Are Dated, Timed And
Signed In Such A Way That The
9. Original Entry Can Still Be Read
Clearly.
12. Jargon, Meaningless Phrases,
Irrelevant Speculation And Offensive
Should Not Be Included.
13. Subjective Statements.
14. Be Readable On Any Photocopies.
15. Preferably Not Include
Abbreviations Or Where They Are
Used, A Clear Explanation Is Easily
Accessible In A Locally Agreed
Abbreviations Glossary.

Types Of Records
In Hospital Setting
1. The Patient Clinical Record.
2. Records Of Admission And
Discharge.
3. A Record Of Nurse's Observation-
Nurses Notes
4. Records Of Orders Carried Out.
5. Records Of Treatment.
6. Records Of Equipment Loss And
Replacement (Inventory)
7. Records Help In The Research For
Improvement Of Nursing Care. 8.
Records Help To Meet Legal
Requirements And Thus Protect The
Workers.
9. Records Help In Nursing Audits. 10.
Records Help In Providing High
Standard Of Service.
11. Records Help In Continuity Of
Service.
12. Records Enable The Person To
Justify His / Her Actions.
In Community Setting
Form Caese Cards And Registers.
 1 Family And Village Record.
2. Eligible Couple And Child Register.
3.Sterilization And Iud Register.
4. Mch Card/Register.
5.Child Card/Register.
6. Birth And Death Register.
7.Sub Centres / Phc / Clinic Registers.
8.Stock And Issue Register.
9. Records Of Blood Stain Of Malaria
And Malaria And Filaria.
10. Malaria Parasite Positive Case
Register And Others.

Other :
. Monthly Report Of Health Workers
(Male And Female)
. Compilation Report Of Health
Attenders (Male And Female)
.  Phc Monthly Report.

In Addition, Each Organizations

Should Maintain :
1. Cumulative Records.
2. Family Records.
In Educational Institutions
5min 1. Student Records.
2. Staff Records.
 To Describe The 3. Academic And Administrative Hand out
Reports. Records. Lecture Cum Discussion
1. Student Record What is reports?
. Application Forms And Other Reports.
. Admission Registers.
. A Cumulative Health Record.
. Class Attendance And Leave Record.
. Clinical And Field Experience, Student
Rotation
.  Internal Assessment Register-Both
Theory And Practical.
10. . Marks List (Board Results/University
Results). Records Of Extra-Curricular
Activities.
. Grade Records For Every Year.
. Practical Record Book-Proceed
2. Staff Record
A. Application
B. Job Description/Functions
C. Periodic Evaluation
F. Leave Record
G. Health Record

10min
REPORTS:
List Out The PPT
Reports Are Oral Or Written Exchanges
Types Of Reports Lecture Cum Discussion
Of Information Shared Between Which area be
Caregivers Or Work In A Number Of used in oral and
Ways. A Report Summarises The written reports?
 Services Of The Person Or Personnel Of
The Agency. Reports Are Usually
Written Daily, Weekly, Monthly Or
Yearly.
Purposes
1. To Show The Kind And Amount Of
Services Rendered Over A Specified
10. Period.
2. To Illustrate In Reaching Goals.
3. As An Aid In Studying Health
Conditions.
4. As An Aid In Planning.
5. To Interpret The Services To The
Public And To The Other Interested
Agencies.
6. They Save Duplication Of Efforts
And Element The Need For
Investigation To Learn The Facts In
Situation.

Types
1. Oral Reports.
2. Written Reports
Oral Reports
Oral Reports Are Given When The
Information Is For Immediate Use And
Not For Permanency.
Example: Oral Report Is Made By The
Nurse Who Is Assigned To Patient Care.
To Another Nurse Who Is Planning To
Relieve Her And Some Of The Oral
Reports May Be Made To Charge
Nurses Supervisors And Also Doctors.
Written Reports
Reports Are To Be Written When The
Information Is To Be Used By Several
Personnel, Which Is More Or Less Of
Permanent Value.
Example: Day And Night Reports,
Census, Inter Departmental Reports And
Other Specific Reports, Needed
According To Situation, Events And
Conditions.
In Hospital Settings
1. Change-Of-Shift Reports.
2. Transfer Reports.
3. Incidence Reports.
4. Legal Reports.
Changing-Of-Shift Reports
These May Be Given Orally In Person
By Audio Taping, Recording, Or During
Rounds At The Client's Bedside. Some
Of The Points To Be Kept In Mind
While Giving Such Reports Are As
Follows:
1. Provide Only Essential Background
Information About Client But Do Not
Review All Routine Care Procedures Or
Tasks.
2. Identify Client's Nursing Diagnosis
Or Health Care Problems And Other
Related Causes Do Not Review All
Biographical Information On Case
Sheets.
3. Describe Objective Measurements Or
Observations About Client's Condition
And Response To Health Problem.
Stress Recent Change But Do Not Use
Critical Comment About Client's
Behavior.
4. Share Significant Information About
Family Members, As It Relates To
Client's Problems. Not Make Any
Assumptions About Relationship
Between Family Members.
5.Continuously Review Ongoing
Discharge Plan. Do Not Engage In Idle
Gossip.
6. Replay To Staff Significant Changes
In The Way Therapies Are Given. Do
Not Describe Basic Steps Of A
Procedure.
7. Describe Instruction Given In
Teaching Plan And Client's Response.
Do Not Explain Detailed Unless Staff
Members Ask For Clarification.
8. Evaluate Results Of Nursing Or
Medical Care Measures. Do Not Simply
Describe Results As Good Or Poor. Be
Specific.
9. Be Clear On Priorities To Which On
Coming Staff Must Attend. Do Not
Force On Coming Staff To Guess What
To Do First.

Transfer Reports
Patients Will Frequently Be Transferred
From One Unit To Another To Receive
Different Levels Of Care. A Transfer
Report Involves Communication Of
Information About Clients From The
Nurse On Sending Unit To The Nurse
On The Receiving Unit. When Giving
Transfer Request, Nurse Should Include
The Following Information :
L. Client's Name. Age. Primary Doctor
And Medical Diagnosis.
2. Summary Of Medical Progress Up To
The Time Of Transfer.
3. Current Health Status-Physical And
Psycho-Social.
4. Current Nursing Diagnosis Or
Problems And Care Plan.
5. Any Critical Assessment Or
Interventions To Be Completed Shortly.
6. For Any Special Equipment Etc.

Incidence Reports
Nurses Usually Become Involved In
Client-Related Incidents At Some Point
In Their Career. They Must Understand
The Purpose Of Incidence Reports And
The Correct Way To Report
Information. While Incident Reporting,
The Following Points Are To Be Kept
In Mind :
1. The Nurse Describes In Concise What
Happened Specifically, Objective Terms
Etc.
2. The Nurse Does Not Interpret Or
Attempt To Explain The Cause Of The
Incident.
3. The Nurse Describes Objectively The
Clients, Conditions When The Incident SUMMARY
Was Discovered. Today I Have Discussed About
4. Any Measures Taken By The Nurse, Records And Reports. And
Other Nurses Or Doctors At The Time Types Of Record And Report,
Of The Incident Are Reported. Tips And Care And Its
5. No Nurse Is Blamed In An Incident Principles
Report.
6. The Nurse Should Never Make
Photocopy Of The Incident Report.

Legal Report:
Incident Reports And Reports Of
Accidents. Mistakes And Complaints
Are Legal In Nature. There Are Times CONCLUSION
When A Hospital Is Criticized For What Maintain good quality records
Is Claimed To Be Negligence Or Poof and reports has both immediate
 Care Because Of A Condition That
Resulted In Discomfort And Perhaps
Serious Harm To A Patient Or Client. In
Such Reports. The Content Is Stated
Briefly And Objectively Giving All
Pertinent Information. Accuracy.
Timeliness. Completeness And
Relevancy To The Problems Are
Maintained Promptly While Making
Such Reports.
The Number And Nature Of Report Will
Depend On Requirement Of Controlling
Body And Nurse. The Preparation
Should Be Done Accurately Because
The Data They Provide Is Frequently
Used For Planning And Evaluating At
State And National Level.
and long-term benefits for
students. In the long term it
protects individuals and teams
from accusations of poor
record-keeping, and the
resulting drop in morale. It also
ensures that the professional
and legal; standing of students
are not undermined by absent
or incomplete records. If they
are called to account at a
hearing.

BIBLIOGRAPHY

 Basavantappa B.T, community health nursing. Page no. 567.

 Keshav swarnkar N.R BROTHER, 2ND edition, community health nursing. Page no. 113- 115, 117, 97, 667.
 Pramilaa R JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD, Nursing communication and education technology. Page
no. 377.
 Mahjan gupta, textbook of preventive & social ,Medicine, JAYPEE PUBLICATION. Page no. 200.