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• 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
  • 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

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

  • Saves time by ensuring records can be found easily and quickly
  • Save space by preventing records from being kept longer than necessary
  • Saves money by reducing storage costs and maintenance costs
  • Improves efficiency by ensuring records are readily accessible legally
  • Improves compliance by keeping records in line with legal and regularly requirements
  • Keeps records under control by preserving data and preventing accumulation control of referral material
  • Improves the quality of information, providing staff with access to accurate and reliable quality records security
  • Increases the security of confidential records continuity
  • Support business continuity and risk management
  • Records are managed efficiently and can be easily assessed and used
  • Records are stored as cost effectively as possible and when no longer required they are disposed of in a timely and efficient manner
  • Complies with requirements concerning records and records management practices to ensure compliance with institution
  • Records of longer term value are identified and protected for historical and other research
• Classification of Records


  • Active Records - a record that is regularly referenced or required for current use
  • Inactive Record - a record that is still needed by an organization but not for current operations
  • Electronic Record - a record recorded or formatted only a computer can process
• Records


  A permanent written communication that documents information relevant to a client's health care management
• Sample of Records


  • Administrative records of Grants/Contracts - Bid documents 1
  • 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 send to medical center chief/medical director
  • Leave record, duty roster, minutes of the meeting, budget etc.
  • Miscellaneous: circular log book, formats, etc.
• 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 of the administration
  • Handed carefully, not destroyed
  • Identified with bio-data of the patients such as name, age, admission number, diagnosis, etc.
  • Never sent outside the hospital without the 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 for the ward
  • The 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 that are essential for programmed planning and evaluation
  • Provide the practitioner with data required for the application of professional services for the improvement of family health
  • 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 the long term changes related to services
• 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
  • Protect doctor in legal issues - 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 involved in the care
  • 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 of the organization's functions, activities, decisions, transactions, procedures, etc.

  2. Identify and apply an appropriate security classification

  3. Distinguish between records and non-record copies or working documents, to be able to appropriately segregate them in the filing system

  4. Place the record in an organizational classification scheme (or file plan) either in paper (e.g. in a filing cabinet or a binder) or in electronic version (e.g. on a shared drive or in a system) to ensure that it's preserved within its context
• Records lifecycle - Active Phase

  1. Preserve the integrity of the record, which means ensuring that it has not been altered after completion

  2. Maintain its usability which means making it available for all colleagues who need an access to the record to do their job

  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 (paper) or systems/shared drives (electronic)

  2. Organize and list them

  3. Transfer them to the local Records Center (for field missions the local Records Center within mission area; for HQ offices the ARMS Records Center)

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

  1. Identify records with archival value (permanent retention), list them, organize them

  2. Identify records due for disposal/destruction, list them, gather necessary approvals for the destruction and proceed with an environmentally friendly destruction process
• More and more research and data about the physical and mental strain of nursing have come out. This should prompt health care leaders to take the initiative to acknowledge and treat this issue about nurses providing for their self-care in a profession that is gradually taking its toll on their physical and mental health
• Psychiatry, obstetrics, gerontology is steadily growing. Enables nurses to develop expertise in the area in which he or she is providing care. Opens the door to opportunities for career advancement. Patients are assured of high level of knowledge and competence in a specific area of care
• Nurses to set up their own businesses. For nurses who value independence and autonomy, entrepreneurship may be a good fit
• Patients gain access to doctors and nurses through video and phone - consults, remote monitoring, and other electronic communication. Serves 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. 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. Pre-covid, it was an option, but with the pandemic it is now the trend. Gave rise to an increasing need for nurse educators
• As baby boomers age the demand for health care services arrows
• The Code of Ethics for Nurses states that Advocacy is also a nurse's responsibility. And as the biggest group of health care providers locally and internationally, nurses have a significant opportunity to express a voice in the future of health care and the health of the nation
• Every day new health care technologies enter the market. Nurses are required to adapt to these technologies in order to improve patient care. Technology is introduced to reduce administration time, increase accuracy all keeping clinician satisfaction and the patient experience in mind