Types of Recording

Administrative Records

It is the record which pertain to the origin, development, activities, and accomplishments of the agency These generally fall into two categories: policy records and operational records.

• Policy Records: Records that relate to the organization such as plans, methods, techniques, or rules which the agency has adopted to carry out its responsibilities and functions. It is further divided to
  • Organizational Documents: Budgets and budget planning records, fiscal records, organizational and functional charts,
  • Governing Documents: Manuals, directives, orders, and interpretations issued from top authority levels, correspondence files of high-level officials, regulations, circulars, instructions, memoranda or of action, and staff studies or special reports relating to methods of workloads and performances.
  • Reporting Documents: Annual reports, periodic progress or summary reports, special reports or accomplishment, transcripts of hearings, minutes of meetings and conferences, and agency
• Operational Records: Records necessary to implement administrative policies, procedures, and histories. operations. The operational value is the usefulness of a record in the conduct of an organization's business. Examples include mandates, procedural records, or records that give direction.
  • Legal Records:
    • Records of legal value include those with evidence of legally enforceable rights or obligations of the State. These may include:
      • Records relating to property rights: land, probate, contracts, agreements, leases, licenses.
      • Records relating to citizenship rights: vital statistics, such as birth, death, marriage, some legal proceedings, and criminal cases.
      • Records relating to employment: veterans' records involving legal rights attached to employment, basic state personnel records, and, in some cases, payroll records.
      • Records containing information required to protect the State against claims or to enforce statutes: executive orders, rules, regulations, and records to establish or support judicial opinions and interpretations.
  • Fiscal Records: Records that have fiscal value relate to an agency's financial transactions. These may be budgets, payrolls, vouchers, and accounting records. After records have served their primary administrative purpose, it may be necessary to preserve them to document the expenditure of public monies and to account for them for audit purposes and requirements.
  • Historical Records: Records are also kept to protect citizens' legal rights and for research in many fields to advance general knowledge and understanding.
  • Research Records: Records used in scholarly studies and investigations. Researchers want to extend human knowledge using basic historical evidence. These records may include important information on individuals, corporate bodies including their problems and conditions, and significant historical events. Researchers may include case files and correspondence of a regulative and quasi-judicial nature, statistical and other data on economic development, population changes, and/or major movements in our society Many of these records have informational, administrative, and archival value.
  • Electronic Records: Electronic record as "a record created, generated, sent, communicated, received or stored by electronic means, including, but not limited to, facsimiles, electronic mail, telexes and internet messaging".
  • Ward Records: Patient's clinical record are instruction book, round register, attendance register, drug maintenance register, admission record & discharge record, census record, call book, complaint book, visitors record, indent book, stock & issue register, treatment record & death register, medical/ nurse's records: nurse's assessment sheet, change of shift record, standardized care plan, nurse's report book, nurse's progress notes, treatment chart, graphic sheet etc.

Types of Reporting

The purpose of reporting is to communicate specific information to a person or group of people.

Change-of-shift report

A change-of-shift report is a meeting between healthcare providers at the change of shift during which vital information about the patient and responsibility for the patient is transferred from the outgoing to the incoming provider. Continuity of care for clients is to be provided by providing new caregivers with a quick summary of client needs and details of care.

Telephone Reports

Health practitioners routinely speak over the phone about a client's information. Nurses notify primary care professionals when a client's condition changes. - When receiving a phone report, the nurse should record the date and time, the name of the person providing the information, and the subject of the information received. To ensure accuracy, the person receiving the information should repeat it back to the sender.

Telephone Orders

Doctors frequently order therapy for their patients over the phone. While the primary care practitioner is issuing the order, write it down and read it back to check accuracy. They inquire about any order that is confusing, unusual, or contrary to the client's medical situation.

Nursing Rounds

Procedures are done to:

• Obtain information that will help plan nursing care
• Provide clients the opportunity to discuss their care
• Evaluate the nursing care the client has received.
• During rounds, the nurse assigned to the client provides a brief summary of the client's nursing needs and interventions being implemented.

Incident Reports, or Occurrence Reports

They are used to record any unexpected incident or mishap that occurs while providing client care, such as falls or prescription errors. These reports are intended to improve quality and should not be used to take disciplinary action against employees. Incident reports improve patient care and treatment by detecting high-risk patterns and launching in-service training to prevent future issues.