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Medical record report

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Meeqat Hospital, Madina.KSA

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Medical record report

  1. 1. Medical record and file arrangement RAHIMA M. SALENDAB, BSN, RN NQMC, MGH, KSA
  2. 2. DEFINITION OF MEDICAL RECORD ‫تعريف السجل الطبي‬
  3. 3. IMPORTANCE OF MEDICAL RECORD ‫أهمية السجل الطبي‬
  4. 4. The required information in the medical record ‫المعلومات المطلوب في سجل الطبي‬ 1. Information relatED to patient and patient care rendered ‫1- معلومات لها صلة بالمريض او العناية به مثل‬ 2. Visual information from the nurse / personal information from the same patient ‫2- معلومات مرئية من الممرضة شخصية من المريض نفسه‬ 3. Information About the time and date ‫3- معلومات الوقت و التاريخ‬ 4. Information on how to give treatment ‫4- معلومات إعطاء العالج‬ 5. Information on verbal order ‫5- معلومات األوامر الشفهية‬
  5. 5. File arrangement 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 REGISTRATION FORM DETAILED PATIENT INFORMATION ADMISSION / DISCHARGE FORM ADMISSION COVER SHEET ADMISSION SHEET ADMISSION ASSESSMENT FORM DISCHARGE SUMMARY FORM DISCHARGE FORM FROM ISTALAMAT (adaption Receipt of the patient, Patient information, Adoption of Discharge) DAMA FORM HISTORY/PHYSICAL EXAMINATION FROM ER PAPER DOCTORS ORDER NURSES NOTES MEDICATION SHEET TPR SHEET PAIN ASSESSMENT & REASSESSMENT FORM VIP (VISUAL INFUSION PHLEBITIS)SCORE FORM DIABETIC FORM CHANGE OF POSITION FORM SUMMARY OF LABORATORY RESULTS LABORATORY RESULT ECG MOUNTING REFERRALS CONSULTATION RESULT (U/S, CXR, CT SCAN, MRI, etc…) CONSENT OR PRE – OP CHECK LIST ANESTHESIA FORM POST – OP FORM TRANSFUSION DATA FORM PATIENT IDENTIFICATION FORM OTHERS
  6. 6. Models of nursing documentation in progress notes ‫أنماط التوثيق التوريضي في نموذج مالحظات التطور‬ 1. Narrative documentation ‫1 – التوثيق بشكل سردي قصصي‬ DATE TIME 01/01/1434 O7:30H 08:00H 08:45H 09:00H 12:30H 15:30H PROGRESS Received pt on bed awake, conscious and oriented, afebrile, with IV cannula size 22G in left arm, with ongoing IV Normal Saline 500 cc at the level of 200 cc, infusing well ------------------------------------------- V/S checked and recorded ------------------------------- Seen and examined by Dr. Musa with orders made and carried out --------------------------------------------- Blood for CBC extracted, sent to lab - Lunch served, ate with fair appetite -------------------- To keep NPO post-midnight for possible OR tomorrow --------------------------------------------------M.E. - Fax send to KFH for CT brain -------------------------“Late entry” abdominal ultra sound done at 10:30H, report seen by Dr. Musa --------------------------------- Closely watched and attended --------------------- Endorsed --------------------------------------------------- SIGNATURE - A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi Amal AlHarbi
  7. 7. ‫‪2. Problem oriented documentation‬‬ ‫1 – التوثيق بشكل تحديد المشكالت‬ ‫)‪a. Method of (soap) or (soapie‬‬ ‫أ – السلوب ال )‪ (soap‬أو ال )‪(soapie‬‬ ‫المعلومات المأخوذة من المريض‬ ‫‪S: subjective‬‬ ‫المعلومات المالحظة من قبل المرضة‬ ‫‪O: objectivce‬‬ ‫المشكالت الصحية للمريض‬ ‫خطة العالج‬ ‫نشاطات تنفيذ الخطة‬ ‫تقييم المجريجات‬ ‫‪A: assessment‬‬ ‫‪P: planning‬‬ ‫‪i: intervention‬‬ ‫‪E: evaluation‬‬ ‫‪Con’t‬‬
  8. 8. a. Method of (soap) or (soapie) (soapie) ‫( أو ال‬soap) ‫أ – السلوب ال‬ S: subjective WHAT PATIENT TELLS YOU (COMPLAIN OF ABDOMINAL PAIN) O: objectivce WHAT YOU OBSERVE, SEE (IS PALE AND HOLDING HIS/HER RIGHT SIDE) A: assessment WHAT DO YOU THINK IS GOING ON BASED ON YOUR DATA (RECURRING ABDOMINAL PAIN) P: planning WHAT ARE YOU GOING TO DO (CHECK V/S, PUT ON NPO AND NOTIFY PHYSICIAN) i: intervention SPECIFIC INTERVENTIONS IMPLEMENTED E: evaluation PATIENT RESPONSE TO THE INTERVENTION
  9. 9. If you are not willing to learn, No one can Help you. )‫(إذا لم تكن على استعداد للتعلم, ال يستطيع أحد مساعدتك‬ If you are determined to learn, No one can stop you …!!! (....‫)إذا كنت عازمة على التعلم, ال يمكن ألحد إيقافك‬ NO ONE CAN MOTIVATE YOU…. IF YOU ARE NOT WILLING TO DO YOUR SELF… ‫(ال احد يمكن أن تحفزلك إذا لم تكن على استعاداد للقيام‬ )‫نفسك‬ THANK YOU

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