Records

Records

Definitions-

"A record is a permanant written communication that documents information relevant to a client health care management."

(According to Potter and Perry)

"It is a written communication that permanently documents information relevent to a clienty health care management. It is a continuing account of the client's health care needs." (According to Sr. Mary Lucital)

Purposes-

It is providing information.
It helps in making studies for research.
It is a tools of communication.
It helps in planning budget and provides statistical data.
It serves as a legal evidence of the services rendered by each employee or worker.
It is providing basis for quality review.
It is providing data for education and research.
It helps the administrator to assess the health assets and need of the community.
It helps to avoid errors or overlapping of work.
It is a record indicates planes for future.
It helps to coordinate the work of nursing staff with other personnel.
It provides justification of expenditure of funds.

Principles of Maintaining Records-

Specific purpose which should be clearly understood.
Items on forms and in registers should be conveniently grouped so as to make their completion as easy as possible.
The wording should be easily understood, and where doubt is likely to arise, instructions to facilitate interpretation should be included.
Records should permit some freedom of expression.
Records which are required by the teaching staff should be easily accessible to them.
Person responsible for maintaining records should be aware of their particular responsibility and every effort should be made to keep records up to date and accurate.
Provision for periodic review of all records to ensure that they keep pace with the changing needs of the programme.
Adequate supply of stationery to permit records to be maintained on the proper forms and in the proper registers at all times.
Sufficient number of filing cabinets and appropriate equipments to operate a filing system which is simple and safe and requires the minimum possible time.
Adequate, safe, fireproof storage arrangements

Types of Records-

Cumulative or Continuing Records- This is found to be time saving, economical and also it is helpful to review the total history of an individual and evaluate the progress of a long period.
Family Records- The basic unit of service is the family. All records, which relate to members of family. Should be placed in a single family folder. This gives the picture of the total services and help to give effective, economic service to the family as a whole. Separate records forms may be needed for different types of service such as TB, maternity etc.
Ward Records - Patient clinical record instruction book, round register, attendance register, drug maintenance register, Admission record and discharge record, census record, call book, complaint book, stock and issue register, treatment record and death register.
Medical/Nurses Records- Large part of the client's records are filled by nurses. Nurse's assessment sheet change of shift record. Standardized care plan, nurses report book, nurses progress notes.

Importances -

Important Characteristics-
Principles and guidelines for quality documentation and recording-

Factual-A factual record contains descriptive, objective information about what a nurse sees,hears,fells,and Smell’s. E.g.A client BP is 80/50 mmHg, client diaphoretic,restlesness, and HR is 102 and regular.*(the use of inferences client appears to be in shock) Without supporting factual data is not acceptable because it can be misunderstood.
Accurate-The use if exact measurements establishes accuracy. Use of an institution accepted abbreviations,symbols and system of measures.
Completness- The information will not be completed without full information. The information within a record entry or a report needs to be complete, containing appropriate and vital information otherwise it’s considered incomplete.
Current. Timely documentation and recording is an vital principles in documentation. To increase accuracy , quality of care and decrease unnecessary duplication and preventing errors it’s essential to record timely. For e.g a client BP is 140/90 when you’re admission of some type of drugs the nude should records same.
Organized- As a nurse you want communicate information in a logical order. For e.g an organized note describes the client’s knowledge deficit, nurses assessment and interventions, and the client’s response. The nurse should applying theories, critical thinking, EBP, and the nursing process gives logic and order to nursing documentation.

Uses of Records