Types of records and common record keeping forms & computerized documentation

common records used in hospital

1. Types Of Records And Common Record Keeping Forms By: Mr. M. Shivananda Reddy

2. TYPES OF RECORDS Hospital records are broadly classified into four categories based on the area of usage. They are: Patients clinical record Individual staff records Ward records Administrative records with educational value.

3. PATIENTS CLINICAL RECORDS It is the knowledge of events in the patient illness, progress in his or her recovery and the type of care given by the hospital personnel . These are Scientific and legal Evidence to the patient the his /her case is intelligently managed. Avoids duplication of work. Information for medical and legal nursing research. Aids in the promotion of health and care. Legal protection to the hospital doctor and the nurse.

4. Examples: Physician’s order sheet Nurse’s admission assessment Graphic sheet and flow sheet- vital signs, I/O chart Medical history and examination Nurses’ notes Medication records Progress notes

5. INDIVIDUAL STAFF RECORDS . A separate set of record is needed for each staff , giving details of their sickness and absences, their carrier and development activities and a personnel note

6. WARD RECORDS . These are the records pertaining to a particular ward. Circular record Round book Duty roaster Ward indent book Ward inventory book Staff patient assignment record Student attendance and patient assignment record

7. ADMINISTRATIVE RECORDS WITH EDUCATIONAL VALUE. Treatment register. Admission and discharge register. Personnel performance register. Organogram / organization chart Job description Procedure manual

8. Common Record Keeping Forms

9. A variety of paper or electronic forms are available for the type of information nurses routinely document. The categories within a form are usually derived from institutional standards of practice or guidelines established by accrediting agencies

10. Admission Nursing History Forms A nurse completes a nursing history form when a patient is admitted to a nursing unit. The form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems.

11. Flow Sheets and Graphic Records Flow sheets allow you to quickly and easily enter assessment data about a patient, including vital signs and routine repetitive care such as hygiene measures, ambulation, meals, weights, and safety and restraint checks.

12. flow sheets help team members quickly see patient trends over time and decrease time spent on writing narrative notes . Critical and acute care units commonly use flow sheets for all types of physiological data.

13. Patient Care Summary or Kardex Kardex forms have an activity and treatment section and a nursing care plan section that organize information for quick reference . An updated Kardex eliminates the need for repeated referral to the chart for routine information throughout the day .

14. The patient care summary or Kardex includes the following information: • Basic demographic data (e.g., age, religion) • Health care provider’s name • Primary medical diagnosis • Medical and surgical history • Current orders from health care provider (e.g. dressing changes, ambulation, glucose monitoring) • Nursing care plan • Nursing orders (e.g., education sessions, symptom relief measures, counseling ) • Scheduled tests and procedures • Allergies

15. Standardized Care Plans Some institutions use standardized care plans. The plans, based on the institution’s standards of nursing practice, are pre-printed , established guidelines used to care for patients who have similar health problems. After completing a nursing assessment, the nurse identifies the standard care plans that are appropriate for the patient and places the plans in his or her medical record. The nurse modifies the plans to individualize the therapies.

16. Progress Notes Progress notes made by nurses provide information about the progress a client is making toward achieving desired outcomes.

17. Discharge Summary Forms Discharge documentation includes Medications Diet Community resources Follow-up care Who to contact in case of an emergency or for questions

18. ACUITY RECORDS Although acuity records are not part of a patient’s medical record, they are useful for determining the hours of care and staff required for a given group of patients. A patient’s acuity level, usually determined by a computer program, is based on the type and number of nursing interventions required over a 24-hour period . The patient-to-staff ratios established for a unit depend on a composite gathering of 24-hour acuity data

19. Most Common Documents In Patient Record: Admission sheet Physician’s order sheet Nurse’s admission assessment Graphic sheet and flow sheet- vital signs, I/O chart Medical history and examination Nurses’ notes Medication records Progress notes results from diagnostic tests (e.g., laboratory and x-ray film results ) consent forms Discharge summary Referral summary

20. COMPUTERIZED DOCUMENTATION

21. Computerized documentation Nurses use computers to store the client’s database, add new data, create and revise care plans, and document client progress.

22. Computerized charting- advantages Increases the quality of documentation and save time. Increases legibility and accuracy. Facilitates statistical analysis of data. The system links various sources of client information.

23. Computerized charting- disadvantages Client’s privacy may be infringed on if security measures are not used. Breakdowns make information temporarily unavailable. The system is expensive. Extended training periods may be required when a new or updated system is installed.

24. Precautions during Computerized charting Password . Never share. Change frequently. Make sure terminal cannot be viewed by unauthorized persons.