Documentation and Information System in Relation of Antenatal

Introduction

Effective case management requires good documenting procedures. The development of programs and policies is based on an evaluation of a program's effectiveness and epidemiological trends in the nation. For high-quality patient care and accurate information sharing, effective and accurate recording and reporting systems, whether paper-based or computerized, are necessary. Modify national or local records to include all pertinent parts required to document critical details about the lady, her family, and the provider for the purposes of monitoring, surveillance, and official reporting.

The WHO's suggested system for recording and reporting entails thorough forms for every patient that are filled out at the point of care and then condensed in laboratory and medical records. At the basic management unit, the data are then combined to create quarterly reports on operations and outcomes as well as annual management reports.

Definition 

Record 

• A record is a permanent written communication that contains data important to managing a client's health care. The act of recording involves gathering data that is generated throughout service delivery and work-in-progress. This is the reporting system's very first and most crucial function. When a service is rendered and a task is completed, records are produced. For continuity of care, planning and evaluating the client's care, as well as for communication between healthcare professionals and between care facilities, accurate record keeping is essential. Each time a woman or newborn receives care, the healthcare facility creates and keeps a record, which the healthcare worker consults and updates.

Reports

• Reports are written or spoken exchanges of information between nurses or other people. Information is communicated to another person by reporting. If accurately recorded, the records help with reporting at many different levels and ultimately support planning, monitoring, and evaluation.
• A well-organized compendium of data and records.
• Information on development.
• Results and findings dissemination.
• A legal duty to the institutions

Legal and ethical issues "The nurse has an obligation to safeguard the confidentiality of all patient information" (ANA code of ethics 2001). In client conferences, clinics, rounds, client studies, and written papers, the records are utilised. It is the duty of the student or health professional to maintain the client's privacy by excluding any identifying information from the notations, including the client's name.

Qualities of reliable records and reports

Good reports and records have the following qualities:

• Structured
• Stuck to goal and objectives of the program.
• Subject specific
• Timely
• Based on complete and reliable data
• Reliable
• Complete

 Importance of Recording and Reporting

• The record acts as a channel for communication between various healthcare providers who work with a client.
• Each healthcare provider plans the client's care using information from the client's record.
• An audit is a look of client records for the goal of quality control.
• An important source of data for research is information found in records. Information useful in treating other customers can be found in the treatment plans for a number of patients with the same medical issues.
• A record can frequently offer a thorough understanding of the patient, sickness, efficient treatment methods, and variables influencing the course of the condition.
• The client's file is a legal record and is typically admissible as evidence in court.
• It helps healthcare planners pinpoint the needs of the organization.
• Records reflect the patient's and family's accepted health state.
• It aids nurses in the implementation of nursing care and short-term planning for nursing.
• It avoids duplication of services and facilitates efficient follow-up care.
• It aids the nurse in assessing the assistance and instruction she has provided.
• It aids in the nurse's efficient use of time and orderly organization of her workload.
• It acts as a roadmap for career advancement.
• It enables the nurse to evaluate the effectiveness and volume of work performed.
• Records assist people in becoming conscious of and identifying their healthcare requirements.
• Record acts as a manual for diagnosis, treatment, and service evaluation.
• The record identifies families in need of services and those willing to receive assistance.
• It allows him to alert the nurse to any important observations he has made.
• The record aids the supervisor in assessing the work done, the instruction given, and the behaviors and responses of a person.
• The use of planned records as an evaluation tool during conferences aids in staff and student assistance.

Information types recorded in each client's file

• Personal data (client name, age, address, and phone number)
• Primary complaint
• findings from the patient's history, physical examination, and other diagnostic investigations.
• Identification of the issue is part of the interpretation of the results or evaluation.
• The specifics of the care plan, including any modifications to the birth readiness and complication readiness plans.
• Prophylaxis, guidance and counseling, as well as therapies for certain issues are all included in the care given.
• Referrals made
• Outcomes 
• Plans for follow up/return visit

 Practical guidelines for taking clear, concise, and accurate records

• Immediately prepare/update client records (during or immediate after visit). Information that is not promptly documented could be forgotten or recalled inaccurately.
• Keep track of all symptoms and indicators that can be used to interpret the results, such as mild to moderate anemia (e.g., hemoglobin 9g/dl, moderate fatigue, respiration 26/m*).
• When interpreting the findings, take note of any absence of symptoms or indications (e.g., hemoglobin 10g/d*l low fatigue, normal respiration 16/m*in pink conjunctiva- assessed mild to moderate anemia).
• When appropriate, record precise numbers and measures (such as blood pressure: 120/95 as opposed to somewhat increased blood pressure).
• Make a distinction between the client's subjective experience and the clinician's observations (e.g. woman feels hot to touch versus woman reports feeling feverish).
• Present findings with as much objectivity and judgment as you can, and present them as facts rather than opinions (e.g. "woman has not taken medicine" rather than woman is uncooperative).