MIDTERM

• Records management (RM) is the supervision and administration of digital or paper records, regardless of format
• Records management


  A systematic and effective control of records (both paper and electronic)
• Records management


  • Ensures records are accurate and reliable, can be retrieved speedily and efficiently, and are kept for no longer than necessary
• Records management activities


  • Creation
  • Receipt
  • Maintenance
  • Use and disposal of records
• Documentation may exist in

  • Contracts
  • Memos paper files electronic files
  • Reports
  • Emails
  • Videos
  • Instant message logs or database records
• Information


  Data, ideas, thoughts, or memories irrespective of medium
• Documents


  Recorded information or objects that can be treated as individual units
• Records


  Information created, received, and maintained as evidence and information by an organization or person, in pursuance of legal obligations or in the transaction of business
• Archives


  Records that have been selected for permanent preservation because of their administrative, informational, legal and historical value as evidence of official business
• Importance of Record Management

  • To provide evidence of actions and decisions
  • To support accountability and transparency
  • To comply with legal and regulatory obligations
  • To protect the interests of staff, students and other stakeholders
  • To help address complaints or legal processes
  • To support patient choice and control over treatment and services
  • To support day to day business of the health care delivery
  • To support evidenced based practice
  • To assist clinical and other types of audits
  • To support sound administrative and managerial decision making
  • To support improvement in clinical effectiveness through research
• Benefits of Record Management

  • Saves time by ensuring records can be found easily and quickly
  • Saves space by preventing records from being kept longer than necessary
  • Saves money by reducing storage and maintenance costs
  • Improves efficiency by ensuring records are readily accessible legally
  • Improves compliance by keeping records in line with legal and regulatory requirements
  • Keeps records under control by preserving data and preventing accumulation
  • Improves the quality of information, providing staff with access to accurate and reliable records
  • Increases the security of confidential records
  • Supports business continuity and risk management
  • Ensures records are stored cost effectively and disposed of in a timely manner
  • Complies with institution requirements concerning records and records management practices
  • Protects records of longer term value for historical and other research
• Classification of Records


  • Active Records - regularly referenced or required for current use
  • Inactive Record - still needed but not for current operations
  • Electronic Record - recorded or formatted only a computer can process
• Records (in nursing)


  A clinical, scientific, administrative and legal document relating to the nursing care given to the individual family and community
• Sample of Records


  • Administrative records of Grants/Contracts - Bid documents
  • Blueprint of facilities
  • Consent forms-adult-minor
  • Endowment Fund Records
  • Equipment inventory reports
  • General ledgers
  • Meeting minutes
  • Payroll folder
  • Contracts-purchase lease rental and etc.
• Records in the Nursing Office and Unit

  • Administrative records: organogram, job description, procedure manual
  • Personnel records: personal files, records
  • Patient records sent to medical center chief/medical director
  • Leave record, duty roster, minutes of the meeting, budget etc.
  • Miscellaneous: circular log book, formats, etc.
• Principles of Record Writing

  • Nurses should develop their own method of expression and form
  • Records should be written clearly and appropriately
  • Records should contain facts based on observation, conversation and action
  • Select relevant facts and the recording should be neat, complete and uniform
  • Records should be written immediately after an interview
  • Records are confidential documents
• Seeking and Release of Records

  • Sentinel events
  • Anecdotal
  • Incident report
  • Kardex
  • Patients chart/records
  • 201 file
• Nurses' responsibility for record keeping and recording

  • Keep under safe custody of nurse
  • No individual sheet should be separated
  • Not accessible to patient and visitors
  • Strangers is not permitted to read records
  • Records are not handed over to the legal advisors without written permission
  • Handed carefully, not destroyed
  • Identified with bio-data of the patients
  • Never sent outside the hospital without written administrative permission
• Nursing Administrator's Responsibility


  • Protection from loss
  • Safeguarding its concerns
  • Completeness
  • Responsibility for nurse notes
  • Admission record
  • Scientific value of the nurse notes
  • Record of order carried out
• Individual Staff Record


  A separate set of record is needed for staff, giving details of their sickness and absences
• Ward Records


  Deducting or increase in beds, change in medical staff and non-nursing personnel, introduction and patient of support
• Characteristic of a Good Record and Reporting

  • Accuracy
  • Consciousness
  • Thoroughness
  • Up to date
  • Organization
  • Confidentiality
  • Objectivity
• Purposes of Record


  • Supply data for programmed planning and evaluation
  • Provide the practitioner with data required for professional services
  • Used as tools of communication between health workers, the family and other development personnel
  • Shows the health problem in the family and other factors that affect health
  • Indicates plan for future
  • Provides baseline data to estimate long term changes
• Administrative Purpose of Clinical Records

  • Legal documents
  • Research or statistics rates
  • Audit and nursing audit
  • Quality of care
  • Continuity of care
  • Informative purposes
  • Teaching purposes of students
  • Diagnostic purposes
• Importance of Records in Hospital - For individual and Family

  • Serve the history of the client
  • Assist in the continuity of cares
  • Evidence to support if legal issues arise
  • Assess health needs: research and teaching
• Importance of Records in Hospital - For the Doctor

  • Serve the guide for diagnosis, treatment, follow up and evaluation
  • Indicate progress and continuity of care
  • Self-evaluation of medical practice
  • Used for teaching and research
• Importance of Records in Hospital - For the Nurses

  • Document nursing service rendered
  • Planning and evaluation of service for future improvement
  • Guide for professional growth
  • Communication tool between nurse and other staff
  • Indicate plan for future
• Importance of Records in Hospital - For Authorities

  • Statistical Information
  • Administrative control
  • Future reference
  • Evaluation of care in terms of quality, quantity and adequacy
  • Help supervisor to evaluate service
  • Guide staff and students
  • Legal evidence of service rendered by each employee
  • Provide justification of expenditure of funds
• Records Lifecycle - Create/Receive


  1. Create complete and accurate records that provide evidence

  2. Identify and apply appropriate security classification

  3. Distinguish between records and non-record copies

  4. Place the record in an organizational classification scheme
• Records Lifecycle - Active Phase

  1. Preserve the integrity of the record

  2. Maintain its usability

  3. Facilitate identification and preservation of records with permanent retention
• Records Lifecycle - Inactive Phase

  1. Identify the records that are not required to be stored in the primary office space

  2. Organize and list them

  3. Transfer them to the local Records Center

  4. Retrieve only those records that are needed from time to time
• Records Lifecycle - Disposition Phase

  1. Identify records with archival value, list them, organize them

  2. Identify records due for disposal/destruction, list them, gather necessary approvals and proceed with destruction
• More and more research and data about the physical and mental strain of nursing have come out, prompting health care leaders to take the initiative to acknowledge and treat this issue about nurses providing for their self-care
• Psychiatry, obstetrics, gerontology is steadily growing, enabling nurses to develop expertise in the area in which he or she is providing care, and opens the door to opportunities for career advancement
• Nurses can set up their own businesses, which may be a good fit for those who value independence and autonomy
• Patients gain access to doctors and nurses through video and phone consults, remote monitoring, and other electronic communication, serving as opportunity for health promotion, wellness checks, and patient care
• In the United States, the number of nurses enrolling in doctoral education programs is growing, specifically for the Doctor of Nursing Practice (DNP) because of the shortage of doctors, while in the Philippines the future of nursing may eventually include mandate to have more doctoral degree nurses but they are mostly in the field of education
• Online classes in the post graduate programs are now being offered by some universities, which gave rise to an increasing need for nurse educators
• As baby boomers age the demand for health care services arrows, and nurses have a significant opportunity to express a voice in the future of health care and the health of the nation through advocacy and action
• Nurses are required to adapt to new health care technologies in order to improve patient care, as technology is introduced to reduce administration time, increase accuracy all keeping clinician satisfaction and the patient experience in mind