RECORDS IN FAMILY HEALTH NURSING PRACTICE Flashcards
shows the extent of the health problems needs and other factors that affect individuals their ability to provide care and what the family believes
RECORDS
What has been done and what needs to be done now can also be shown in here
RECORDS
Provides documentation of the services that have been rendered and supply data that are essential for program planning and evaluation
PURPOSES OF RECORDS
To provide the practitioner with data required for application of professional services for the improvement of family’s health
PURPOSES OF RECORDS
- Tools for communication
- Indicates plans for future
PURPOSES OF RECORDS
Shows the health problem in the family and other factors that affect health
PURPOSES OF RECORDS
Provides baseline data to estimate the long-term changes related to services
PURPOSES OF RECORDS
Nurses should develop their own method of expression and form in record writing
PRINCIPLES OF RECORD WRITINGS
Records should be written, appropriately and legibly
PRINCIPLES OF RECORD WRITINGS
Records should contain facts based on observation, conservation, and action
PRINCIPLES OF RECORD WRITINGS
Select relevant facts and the recording should be neat, complete and uniform
PRINCIPLES OF RECORD WRITINGS
provides basic facts for services.
- Records show health condition as it is and as the patient and family accepts it
VALUES USES OF RECORD
Provides a basis for analyzing needs in terms of what has been done, what is being done, what is to be done and the goal towards which means are to be directed
VALUES USES OF RECORD
Provides a basis for short and long-term planning
VALUES USES OF RECORD
It prevents duplication of services and helps
follow up services effectively
VALUES USES OF RECORD
Helps the nurse to evaluate the care and the teaching which she has given
VALUES USES OF RECORD
helps the nurse organize her work in an orderly way to make an effective use of time
VALUES USES OF RECORD
- It serves as a guide to professional growth
- It enables the nurse to judge the quality and quantity of work done
VALUES USES OF RECORD
- Records help them to become aware of and to recognize their health needs.
-A record can be used as a teaching tool as well
VALUES USES OF RECORD
- Record serves as a guide for diagnosis, treatment, and evaluation of services
- It indicates progress
- It may be used in research
VALUES USES OF RECORD
The record helps identify families needing service and those prepared to accept help
VALUES USES OF RECORD
It enables to draw the nurse’s attention towards any pertinent observation he/she has made
VALUES USES OF RECORD
The record helps the supervisor evaluate the services rendered, teaching done, and a person’s actions and reactions
VALUES USES OF RECORD
It helps in the guidance of staff and students where planned records are utilized as an evaluation tool during conferences
VALUES USES OF RECORD
It helps the administrator assess the health assets and needs of the village or are
VALUES USES OF RECORD
- CUMULATIVE OR CONTINUING RECORDS
- FAMILY RECORDS
TYPE OF RECORDS
Time saving, economical, helpful in reviewing the total history of an individual and evaluate progress of a long period
CUMULATIVE OR CONTINUING RECORDS
One record for home visits/services (blue ink) and clinic visits/services (red ink) which helps coordinate services and saves time
CUMULATIVE OR CONTINUING RECORDS
All family records should be placed in a single-family folder
FAMILY RECORDS
Separate record forms may be needed for different types of services such as TB, Maternity etc. all such individual records which relate to members of one family should be placed in a single-family folder
FAMILY RECORDS
Different Systems may be adopted depending on the purposes of the records and on the merits of a system
FILING OF RECORDS
- Alphabetically
- Numerically
- Geographically
- With index cards
The records should be arranged:
- It provides indication of the total volume of service
and type of cases seen. - Clerical assistance may be needed for this.
REGISTER
Can be of varied types such as immunization register, clinic attendance register, family planning register, birth register, and death register
REGISTER
can be compiled daily, weekly, monthly, quarterly, and annually
REPORTS
- summarizes the services of the nurse and/or the agency.
- may be in the form of an analysis of some aspect of service
REPORTS
Based on records and registers and so it is relevant for the nurses to maintain the records regarding their daily case load, service load, and activities
REPORTS
To show the kind and quantity of service rendered over to a specific period
PURPOSES OF REPORTS
- To show the progress in reaching goals
- As an aid in studying health conditions
PURPOSES OF REPORTS
- As an aid in planning
- To interpret the services to the public and to other interested agencies
PURPOSES OF REPORTS
- The following are statements regarding Family Health Records. Which among the following is correct?
a. All professional persons need to be accountable for the performance of their duties to the public.
b. Records are a practical and indispensable aid to the doctor, nurse and paramedical personnel in giving the best possible service to the clients.
c. Recorded facts have value and scientific accuracy for more than
mere impression of memory and they are guidelines for better administration of health services
all statements are correct
Records serve many purposes depending on who will be utilizing it. The following purposes are applicable for the patient and
the family, EXCEPT:
a. Recognize health needs that can be used for research and health teaching
b. Assist in continuity of care
c. Provide the management with statistical information necessary for decision in regard to utilization of resources
d. Serve as evidence to support or manage legal questions that may arise
B
Identify whether it is a record, registry or report
a. Birth certificate
b. Death certificate
c. Monthly cases census
d. Nursing Progress note
e. Individual performance eval
f. TB monitoring sheet
g. Family profile
REGISTRY = A, B
REPORT = C, E
RECORD = D, F, G
Which among the following is not the purpose of the report?
a. To show the kind and quantity of service rendered over to a specific period
b. To show the progress in reaching goals
c. To interpret the services to the public and to other interested agencies
d. Serves as a guide for diagnosis, treatment and evaluation of services
D
