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INTRODUCTION

Documentation is process of communicating in written form about


essential facts for the maintenance of continuous history of events over a
period of time. Recording and reporting are the other ways of
documentation. Record is the permanent written communication that
document information relevant to a clients health care management.
Record means all documents facilities evaluation of the programme and
provide continuity from the time the institution is established.
DEFINITION OF RECORDS
A record is a clinical, scientific, administrative and legal document
relating to the nursing care given to individual family or community.
DEFINITION OF REPORTS
Reports are oral or written exchanges of information shared
between caregivers or workers in a number of ways.
IMPORTANTS OF RECORDS AND REPORTS
Decision Making:
Records play an important role for making decision. Based upon
the previous data, future planning, even decisions can be made.
Planning Client Care:
Records are very helpful for planning nursing care to the patients.
Communication:
Records and reports are very important for conveying the
information to the employees, employer as well as to the public.
Legal Documentation:
Records are helpful for the legal purposes especially in medico-
legal cases.
Education:
Records are helpful for teaching the nursing as well as medical
students. Medical students learn from the previous records of the
patients.
Research:
Records are the secondary source for data collection while
conducting research, investigator did the recording of all the activities
he/she performed during data collection.

Vital Statistics:
Records are used especially for assessing mortality and morbidity
rate.
PRINCIPLES OF MAINTAINING RECORDS
1. There must be standards framed for record keeping that focuses on
content quality.
2. Record should be for a specific purpose which should be clearly
understood.
3. Records should contain only relevant information and records should not
be duplicated.
4. Records which are required by the teaching staff should be easily
accessible to them.
5. persons responsible for maintaining records should be aware for their
particular responsibility and every effort should be made to keep records
up to date and accurate.
6. There should be sufficient number of filing cabinets and appropriate
equipments to operate a filing system which is simple and safe and
requires the minimum possible time.
7. There should be provision for periodic review of all records.
8. There should be adequate, safe and fire proof storage arrangements.
9. Records should be audited by trained peer auditors at regular interval.

STUDENTS RECORDS
The list of records is;
1. Application forms and other reports – concerning selection and
admission such as references, medical reports, including mark lists,
certificates and results of written test and interview at the time of
selection.
2. Admission Register
3. A cumulative health record
4. Class attendance and leave record
5. Clinical and field experience, student rotation
6. Internal assessment register – both theory and practical
7. Mark list (state council/board results)
8. Records of extra-curricular activities
9. Practical record book
10. Permanent cumulative student record, student details, examination and
results, theory hours, practical experience, marks, rank class for each
student.
11. Student evaluation internal practical and theory
STAFF RECORDS
1. Application form
2. Copy of letter of appointment and any subsequent letter showing change
in status.
3. Job description/functions
4. Record of the staff members
 Educational qualification
 Previous experience
 Any short term educational course attended
 Membership in professional societies and activities
 Contribution of articles to journals
 Holding office in organization
 Participation in seminars, conferences etc updated every year.
5. Periodic evaluation or progress report
6. Leave record
7. Health record
8. Aneedotal record
ADMINISTRATIVE RECORDS
1. Philosophy, purposes and curriculum
2. Course content and course plan record for each subject
3. Record of academic requirements
4. Rotation plans for each academic year
5. Record of committees
6. Record of the stocks
7. Application records
8. Records of educational programmes organized for teaching faculty and
students
9. Annual reports
10. Written policies
11. Statement of budget proposals and allotments
12. Copy of brochure
13. Inspection/accreditation record
14. Minutes of committee meeting
15. Photograph/video/paper cuttings of important events
16. Computerized records (Floppy, CD)

Performance Appraisal is the systematic evaluation of the performance of employees and to


understand the abilities of a person for further growth and development. Performance appraisal is
generally done in systematic ways which are as follows:

1. The supervisors measure the pay of employees and compare it with targets and plans.
2. The supervisor analyses the factors behind work performances of employees.
3. The employers are in position to guide the employees for a better performance.

Objectives of Performance Appraisal


Performance Appraisal can be done with following objectives in mind:

1. To maintain records in order to determine compensation packages, wage structure, salaries


raises, etc.
2. To identify the strengths and weaknesses of employees to place right men on right job.
3. To maintain and assess the potential present in a person for further growth and
development.
4. To provide a feedback to employees regarding their performance and related status.
5. To provide a feedback to employees regarding their performance and related status.
6. It serves as a basis for influencing working habits of the employees.
7. To review and retain the promotional and other training programmes.

Advantages of Performance Appraisal


It is said that performance appraisal is an investment for the company which can be justified by
following advantages:

1. Promotion: Performance Appraisal helps the supervisors to chalk out the promotion
programmes for efficient employees. In this regards, inefficient workers can be dismissed or
demoted in case.
2. Compensation: Performance Appraisal helps in chalking out compensation packages for
employees. Merit rating is possible through performance appraisal. Performance Appraisal
tries to give worth to a performance. Compensation packages which includes bonus, high
salary rates, extra benefits, allowances and pre-requisites are dependent on performance
appraisal. The criteria should be merit rather than seniority.
3. Employees Development: The systematic procedure of performance appraisal helps the
supervisors to frame training policies and programmes. It helps to analyse strengths and
weaknesses of employees so that new jobs can be designed for efficient employees. It also
helps in framing future development programmes.
4. Selection Validation: Performance Appraisal helps the supervisors to understand the
validity and importance of the selection procedure. The supervisors come to know the validity
and thereby the strengths and weaknesses of selection procedure. Future changes in
selection methods can be made in this regard.
5. Communication: For an organization, effective communication between employees and
employers is very important. Through performance appraisal, communication can be sought
for in the following ways:
a. Through performance appraisal, the employers can understand and accept skills of
subordinates.
b. The subordinates can also understand and create a trust and confidence in
superiors.
c. It also helps in maintaining cordial and congenial labour management relationship.
d. It develops the spirit of work and boosts the morale of employees.

All the above factors ensure effective communication.

6. Motivation: Performance appraisal serves as a motivation tool. Through evaluating


performance of employees, a person’s efficiency can be determined if the targets are
achieved. This very well motivates a person for better job and helps him to improve his
performance in the future.