RECORDING AND REPORTING

BAISHALI DEB
1st Year M.Sc. (N)
DEFINITION-

 RECORD-
 A record is a permanent written communication that
documents information relevant to a client’s health care
management. It is a clinical, scientific, administrative
and legal document relating to the nursing care given to
the individual, family or community.

REPORT-
Reports are information about a patient either written or
oral.
PURPOSES OF RECORDS:
Communication
Planning client care
Auditing health agencies
Research
Education
Reimbursement
Legal documentation
Health care analysis
GENERAL GUIDELINES FOR RECORDING:

Date and time

Timing/Frequency
Legibility
Permanence
Correct spelling
Signature
Accuracy
When describing something avoid general words, such
as large, good, or normal, for example, chart specific
data such as ‘2cm*3cm’ bruise rather than ‘large bruise’.
Sequence
Appropriateness
Completeness
Conciseness- recording needs to be brief as well as complete to save
time in communication.
Accepted terminologies/abbreviations
Legal prudence- accurate, complete documentation gives legal protection
to the nurse; the client’s other caregivers, the health care facility, and the
individual. ‘complete charting for example, by using the steps of the
nursing process as a framework, is the best defense against malpractice.’
Ethical and legal consideration.
The nurse has a duty to maintain confidentiality of all patient
information.
VALUES AND USES OF RECORDS:

Records provides basic facts for services. Records show the health condition as it is
and as the patient and family accepts it.
Provides a basis for analyzing needs in terms of what has been done, what is being
done, what is to be done and the goals towards which means are to be directed.
Provides a basis for short and long term planning.
It prevents duplication of services and helps follow up services effectively.
Helps the nurse to evaluate the care and the teaching which she has given.
It helps the nurse organize her work in an orderly way and to make an effective use
of time.
It serves as a guide to professional growth.
It enables the nurse to judge the quality and quantity of work done.
Records help them to become aware of and to recognize their health needs.
Record serves as a guide for diagnosis, treatment and evaluation of services.
It indicates progress.
RECORDS MAINTAINED IN HOSPITAL:

The patient’s clinical record

Records of nurse’s observations- Nurses’ notes
Records of orders carried out
Records of treatment.
Records of admission and discharge.
Records of equipment (inventory).
Records of personal performance.
DEFINITION-

REPORT-
Reports are information about a patient either written
or oral.
–Sr. Nancy
PURPOSES OF WRITING REPORT:

To show the kind and quantity of service rendered over

to a specific period.
To show the progress in reaching goals.
As an aid in studying health conditions.
As an aid in planning.
To interpret the services to the public and to other
interested agencies.
The purpose of reporting is to communicate specific
information to a person or group of people.
 Change of shifts report
 Telephone reports
 Incedent reports
CONCLUSION:

Maintaining records and reports has both immediate

and long term benefits for staff. In long term it protects
individuals and teams from accusations of poor record-
keeping and help in achieving the goal with collective
work.
REFERENCE:

Kaur S, Kaur J. Textbook of nursing management and

services. First edition. New Delhi: Jaypee Brothers
Medical Publishers; 2013

Vati J. Principles and Practice of Nursing Management

Administration. Second edition. New Delhi: Jaypee
Brothers Medical Publishers; 2020