CHN1

MODULE 2 LESSON 2
 Records in Family Health Nursing Practice

RECORDS- refer to the forms on which

information about an individual or family is
recorded.
REPORTS- these are account or statement
describing in detail an event, situation, or like,
usually as the result of observation, inquiry, etc.
a formal or official presentation of facts.
 TYPES OF REPORTS:

• Verbal/Oral Reports- are given when the

information is for immediate use and not for
permanency. E.g. it is made by the nurse who is
assigned to patient care. To another nurse who is
planning to relieve her.
• Written Reports- are to be written when the
information to be used by several personnel, which
is more or less of permanent value. E.g. day and
night reports, census, interdepartmental reports,
need according to situations, events and conditions.
 TYPES OF RECORDS:

Cumulative/Continuing Records
• Gradual increasing and continuing record
procedure
• Review total history of individual
• Evaluate progress for longer period
Family Records
• All records, which relate to members of family,
should be placed in a single family folder. It
helps to give effective, economic service in the
family as a whole.
 Records to be kept under health centers:
Family Folders:
• MCH cards, Antenatal card/ postnatal cards, Infant card, Pre-
school child card
• Medicine distribution card include records of iron and folic
acid distribution cards
• Family welfare records(eligible couple, mtp, family planning),
• Treatment and referral records,
• Vital event records(birth and death records),
• General information records(individual records, family,
village, map of community),
• Other records: antenatal records, Medicine records,
Monthly/ yearly records, Consumable stock register,
Stationary stock register, Daily diary, cumulative records.
 Records to be kept with the patient :
• health record of school going children
• infant health card
• maternal card
• TB patient card
• individual health card
• Birth and death record
• Inpatient and outpatient record
• Eligible couple records
• Movement register
• Medicine stock register
 IMPORTANCE OF RECORDS AND REPORTS:
:

• Assess health level of community

• Helps in collecting data
• Assessment and evaluation of work
• Basis for formulating plans
• Tool or medium for health education
• Determine needs of resources
• Legal documentation
• Means of communication
• Provide information of good nursing
• Conduct training and research work
• Assess health problems
 MAINTENANCE OF RECORDS AND REPORTS:
:

• Filling of records: Alphabetically, numerically

and geographically.
• GUIDELINES:
- Clear, appropriate and readable
- Real or based on facts
- Abbreviations and short forms should be
of standard
- Sentences should be short and clear
- Signature of person filled records
 MAINTENANCE OF RECORDS AND REPORTS:
:

• PRECAUTIONS:
 Kept carefully
 Protected against termites and insects
 Good filling system
 Easily available on time
 Kept at definite place
 Confidential