RECORDS in FAMILY HEALTH NURSING

• All professional person needs to be a__________for the performance of their ____________to the
public.

• Since N________has been considered as profession.

• Nurses need to __________their work on completion.

• _______are a practical and indispensable aid to the doctor, nurse and paramedical personnel in
giving the best possible service to the clients.

• _________summarizes the services of the person or personnel and of the agency.

RECORDS

• Is a _________ ________ _______ that documents information relevant to a clients healthcare

management.

• a record is a _____, ______, administrative and legal document relating to the nursing care given
to the individual family and ________.

• ________are oral to written exchanges of information shared between caregivers or workers in a

number of ways.

• a ______ is the summary of the services of person or personnel and of the agency. that provide
the practitioner with _____that required for the ______ of professional services for the _____of
the family's health.

• serves as a ______of communication between health workers, the family and developmental
personnel.

• _______health records show the health problem in the family and other factors that affect health.

• indicates ______for the future.

• help in the R_______for improvement of nursing care.

PRINCIPLES OF RECORD WRITING

1. N______ should _____their own method of expression and form in record writing.

2. Written clearly, _______ and adequately.

3. Contains______based on ______, conversation and ___.

4. Select relevant facts and the recording should be ____,

complete and Uniform.

5._____legal documents and it should be handled _____

• ______ and accounted for.

6. should be _____ immediately after an ______.

7. are ______ documents.

8. Accurately _____ ,_____ and Signed.

9. Not included abbreviations, _______ meaningless phrases.

10. Serves to ______ the history of the client.

11. Assist the community of ____.

12. Serve as evidence to ____ or to manage the legal questions that arise.

13. ______ the health needs and can be used as a research and _____ tool.
14.____for diagnosis, ______ , _____ and evaluation of services.

15. Indicate_______ and continuity of _____.

16. Help self _______ of medical ________.

17. _____the doctor in case of _______ maybe used for teaching and research.

TYPES OF RECORD

CUMULATIVE OR CONTINUING RECORDS

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

All records which relate to members of family and should be placed in a single family folder.
Gives the picture of the total services and helps to give effective economic service to the family as
a whole.
separate record forms maybe needed for different types of services such as TB maternity.

HOW TO IMPROVE RECORD KEEPING

• Get into the using factual, consistent, accurate, objective and unambiguous patient information.

• Use your senses to record what you did.

• Ensure there is a reasonable rationale for any decision recorded.

• Ensure notes are accurately dated, timed and signed with the name printed alongside the entry.

• Write the notes, where possible with the involvement and understanding of the patient or
caretaker.

• Follow SMART model ( specific, measurable, achievable, realistic and Time bound or time based).
similar when planning care.

• write up notes as soon as possible after an event and by law within 4hrs making clear any
subsequent alterations or additions.

NURSES RESPONSIBILITY FOR RECORD KEEPING

1. The patient has a right to inspect and copy the record after being discharged.

2. Failure to record significant patient information on the medical record makes a nurse guilty of
negligence.

3. Medical record must be accurate to provide a sound basis for care planning.