The document discusses guidelines for proper documentation and reporting in healthcare, including maintaining accurate, complete records for communication, education, and legal purposes. It also outlines the different types of reports like change of shift reports, incident reports, and legal reports that are important for monitoring quality of care. Proper documentation in medical records is essential for continuity of care, research, and evaluating health programs.
This lesson will help the nursing students to learn and know the nursing records and reports and responsibility of the nurse in maintaining nursing records and reports in various health settings.
nursing records and reports, definition, purposes, principles, values and uses, types, records in hospital, types of reports, how to write better report, nursing responsibilities
This lesson will help the nursing students to learn and know the nursing records and reports and responsibility of the nurse in maintaining nursing records and reports in various health settings.
nursing records and reports, definition, purposes, principles, values and uses, types, records in hospital, types of reports, how to write better report, nursing responsibilities
Record and Report in Nursing, Principles of Record and Report, Types of Record and Report, Filling of Record, Value and Uses of Record and Report, Guideline for Documentation,
Record and Report in Nursing, Principles of Record and Report, Types of Record and Report, Filling of Record, Value and Uses of Record and Report, Guideline for Documentation,
For those of you who want to get a head start on the chartsmart, these are the applicable slides. Also, Brenda has a sheet of "Descriptive Terms" that you will want for that project. She handed it out to a few people the other day who wanted to get a head start on the charting assignment.
BIN95.com Newsletter, vol 185 - Maintenance planning and scheduling. The book “MAINTENANCE PLANNING AND SCHEDULING HANDBOOK” by Doc Palmer and published by McGraw Hill presents the recommended way to plan for a maintenance crew. this is a book review.
Project Report on Computer (Basics, MS Word, MS Powerpoint, Email)Nikhil Dhawan
Computers are really great, in every field, every walk of life we are depended on them, Even we think that we know about them (Computers) a lot but when there is the thing that we have to write a report on computers we all started finding it on the Air (Internet).
Project Report on Computer (Basics, Word, Power point and Email)
So, making it clear and easily understandable to students and even other people who want to prepare a report, I wrote this Simple Knowledge Giving Report on Computers it Includes About Computers, Its Components, MS Word, MS PowerPoint & Email.
You only have to remove the headers and footers and then enjoy the free content. No editing required, I Ensure it is 100% Approved report with great content in it.
Hope You will enjoy it.
Medical Record Audit in Clinical Nursing Units in Tertiary Hospitaliosrjce
IOSR Journal of Nursing and health Science is ambitious to disseminate information and experience in education, practice and investigation between medicine, nursing and all the sciences involved in health care. Nursing & Health Sciences focuses on the international exchange of knowledge in nursing and health sciences. The journal publishes peer-reviewed papers on original research, education and clinical practice.
By encouraging scholars from around the world to share their knowledge and expertise, the journal aims to provide the reader with a deeper understanding of the lived experience of nursing and health sciences and the opportunity to enrich their own area of practice. The journal publishes original papers, reviews, special and general articles, case management etc.
Medical Records is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
Medical Records: Intro, importance, characteristics & issuesSrishti Bhardwaj
Unit 1 of MHA SEM- III's syllabus of Medical records Management
(Bharati Vidyapeeth- Center for Health Management Studies & Research, Pune)
Self made- study purpose- reference presentation
avoid hyperlinks on certain slides- inactive
sources shared on last slide as REFERENCES
Hope it helps :)
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stock
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Hot Selling Organic intermediates
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
2. RECORDS
A record is a permanent written
communication that documents
information relevant to a client’s
health care management, e.g. a
client chart is a continuing
account of client’s health care
status and need.
-Potter and Perry
R S MEHTA, MSND 2
3. PURPOSES OF RECORDS
1.Supply data that are essential for programme
planning and evaluation.
2. To provide the practitioner with data
required for the application of professional
services for the improvement of family’s
health.
R S MEHTA, MSND 3
4. 3. Records are tools of communication
between health workers, the family, and
other development personnel.
4. Effective health records shows the health
problem in the family and other factors that
affect health.
5. A record indicates plans for future.
6. It provides baseline data to estimate the
long-term changes related to services.
R S MEHTA, MSND 4
5. Administrative purpose of clinical
records
• Legal documents: poisoning, assault, rape,
LAMA, burn etc.
• Research or statistics: rates
• Audit and nursing audit
• Quality of care
• Continuity of care
• Informative purposes: M E N census
• Teaching purpose of students
• Diagnostic purposes: test reports
6. Importance of Records in Hospital
1. For the individual and family:
- Serve the history of the client
- Assist in continuity of care
- Evidence to support if legal issues arise
- Assess health needs, research and
teaching.
R S MEHTA, MSND 6
7. 2. 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
R S MEHTA, MSND 7
8. 3. For the nurses:
- Document nursing service rendered
- Shows progress
- Planning and evaluation of service for future
improvement
- Guide for professional growth
- Judge the quality and quantity of work done
- Communication tool between nurse and other
staff involved in the care.
- Indicate plan for future
R S MEHTA, MSND 8
9. 4. 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 render by each
employee
- Provide justification of expenditure of funds.
R S MEHTA, MSND 9
10. Purposes of records: summary
1.COMMUNICATION
2.FINANCIAL BILLING
3.EDUCATION
4.ASSESSMENT
5.RESEARCH
6.AUDITING AND MONITORING
7.LEGAL ASPECT
R S MEHTA, MSND 10
11. Records in the nursing office & Unit
- Administrative records: Organogram, job
description, procedure manual
- Personnel records: personal files, records
- Patient related records: patients records send
to Medical director
- Leave record, duty roster, meeting minutes,
budget etc
- Miscellaneous: circular, round book, formats etc
R S MEHTA, MSND 11
12. PRINCIPLES OF RECORD WRITING
1. Nurses should develop their own
method of expression and form in
record writing.
2.Records should be written clearly &
appropriately.
3.Records should contain facts based on
observation, conversation and action.
R S MEHTA, MSND 12
13. 4. Select relevant facts and the recording
should be neat, complete and uniform
5.Records should be written immediately
after an interview.
6. Records are confidential documents.
R S MEHTA, MSND 13
14. FILLING OF RECORDS
Different systems may be adopted
depending on the purposes of the records
and on the merits of a system.
The records could be arranged:
– Alphabetically
– Numerically
– Geographically and
– With index cards
R S MEHTA, MSND 14
15. REGISTERS
• It provides indication of the total volume of
service and type of cases seen. Clerical
assistance may be needed for this.
Registers can be of varied types such as:
• immunization register,
• clinic attendance register,
• family planning register,
• birth register and
• death register.
R S MEHTA, MSND 15
16. GUIDELINES FOR QUALITY
DOCUMENTATION AND
REPORTING….
a) Factual basis
b) accuracy
c) completeness
d) accuracy
e) organization
f) confidentiality
R S MEHTA, MSND 16
17. NURSES RESPONSIBILITY FOR
RECORD KEEPING AND REPORTING
• Keep under safe custody of nurses.
• No individual sheet should be separated.
• Not accessible to patients 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.
R S MEHTA, MSND 17
18. cont..
• Identified with bio-data of the patients
such as name , age, admission number,
diagnosis, etc. (Legal Issues?)
• Never sent outside of the hospital without
the written administrative permission.
R S MEHTA, MSND 18
19. Patient Verification
• Two identifiers: patient name and date
of birth
• Compare to ID band, consents, diagnostic
images, and all other patient
documentation related to the procedure
20. SYSTEM OF MEDICAL RECORD
• In the modern age, Medical Record has its
utility and usefulness and is a very broad
based indicator of patients care.
• The policy is to keep indoor patient Records
for 10 years
• The OPD registers for 5 years
• The record which is register for legal
purposes in Maintained for 10 years or till
final decision at the court of Law.
R S MEHTA, MSND 20
21. FUNCTIONS OF MEDICAL RECORD DEPARTMENT
1. Daily receipt of case sheets pertaining to
discharge and expired patients from various
wards, there checking and assembly.
2. Daily compilation of Hospital census report.
3. Maintains & retrieval of records for patient
care and research study.
4. Completion and Procession of Hospital
statistics and preparation on different
periodical reports on morbidity and
mortality.
22. 5. Online registration of vital events of
Birth & Death.
6. Issuing Birth & Death certificated up
to one year.
7. Dealing with Medico Legal records
and attending the courts on
summary.
8. Arrangement & Supervision of
enquiry and admission office.
R S MEHTA, MSND 22
24. • Reports can be compiled daily, weekly, monthly,
quarterly and annually.
• Report summarizes the services of the nurse and/
or the agency.
• Reports may be in the form of an analysis of some
aspect of a service.
• These are based on records and registers and so
it is relevant for the nurses to maintain the records
regarding their daily case load, service load and
activities.
• Thus the data can be obtained continuously and
for a long period.
R S MEHTA, MSND 24
25. NURSING REPORTS
o Reports are information about a patient
either written or oral.
-sr. Nancy
o A report is a summary of activities or
observations seen, performed or heard.
-Potter and Perry
R S MEHTA, MSND 25
26. PURPOSES OF WRITING REPORTS
• To show the kind and quantity of service
rendered over to a specific period.
• To show the progress in reaching goals.
• As an aid in studying health conditions.
• As an aid in planning.
• To interpret the services to the public and to
other interested agencies.
R S MEHTA, MSND 26
27. TYPE OF REPORTS
1)Change of shift report
2) telephone reports
3)Telephone orders
4)Transfer reports
5)Incident reports
6)Legal reports
R S MEHTA, MSND 27
28. CRITERIA OF GOOD REPORT
Can be made promptly
Clear, concise and complete
All pertinent, identifying data included
Mention all people concerned, situation
and signature of person making report
Easily understood
Important points are emphasized
R S MEHTA, MSND 28
29. Key Messages
• Written policies and procedures are
the backbone of the quality system
• Complete quality assurance records
make quality management possible
• Keeping records facilitates meeting
program reporting requirements
29
30. • Records and reports revels the
essential aspects of service in
such logical order so that the
new staff may be able to
maintain continuity of service
to individuals, families and
communities.
R S MEHTA, MSND 30
33. What are Electronic Medical Records?
The IOM 2003 Patient Safety Report describes an EMR as
encompassing:
– “a longitudinal collection of electronic health information
for and about persons
– Immediate electronic access to person- and population-
level information by authorized users;
– Provision of knowledge and decision-support systems
that enhance the quality, safety, and efficiency of patient
care and
– Support for efficient processes for health care delivery.”
34. What are Electronic Medical Records?
The 1997 IOM report “The Computer-Based Patient
Record: An Essential Technology for Health Care”
defines an EMR as:
“A patient record system is a type of clinical
information system, which is dedicated to
collecting, storing, manipulating, and making
available clinical information important to the
delivery of patient care.
The central focus of such systems is clinical data
and not financial or billing information.”
35. What are Electronic Medical Records?
The American Health Information Management
Association defines three essential capabilities of an
EMR:
1. To capture data at the point of care,
2. To integrate data from multiple internal and
external sources, and
3. To support caregiver decision making.
36. Implementing an EMR in LTC
Leadership Support
Pre- Change Peer Mentor & Go Live & Account
Implementation Management Training Support Management
Optimum User Adoption
& Customer ROI
37. Records Should be Permanent,
Secure, Traceable
• Permanent: • Traceable:
– Sign and date every
– Keep books bound
record
– Number pages
– Use permanent ink
– Control storage
• Secure:
– Maintain confidentiality RECORDS
– Limit access
– Protect from
environmental hazards
37
38. Summary
• What is the difference between a document and
a record?
• What are some examples of documents and
records?
• Name examples of information not found in a
manufacturer product insert.
• What are some key features of SOPs?
• What are some tips for good record-keeping?
• How should records be maintained?
• How are test site records reported in your
country?
38
39. Transfer of Patients
• Transferring unit will change the status of any
appropriate interventions from “Active” to
“Complete” by clicking in the Status column
– Completed Admissions Documentation
– System Flowsheet
• Receiving unit stops all nursing orders initiated
in order entry, enters transfer orders according
to policy and procedure, and the nurse will add
on the correct system flowsheet for the patient
on the intervention list using the “Add
Intervention” Function
40. Order Entry
• All paper physician order sheets
must be faxed to pharmacy upon
admission
• Pharmacy will enter any medications and IVs
into Meditech – the list of current medications
can be viewed in the EMR by clicking on the
Medications tab
• All non-medication orders will be entered by
the nurse or secretary into the Meditech order
entry system
41. Order Entry
• It is the RN’s responsibility to verify ALL orders
(lab, radiology, nursing, etc.) are entered into
Meditech from the Physician Order Sheet (Use
Order History in the EMR)
• Initial each individual order with red ink after
verification that the order is in Meditech
• After all orders have been entered and verified, a
Kardex will be printed from the Meditech desktop
using the Reports button
42. Verification of Physician Orders
• For ancillary department orders requiring
pager notification (Respiratory Therapy)
the time of the page is written on the order
sheet next to the order
• Co-sign each set of
physician orders with
initials, title, date, and time
43. 24-hour Chart Checks
• Performed on 11pm – 7am shift
• Review ALL orders written during the
previous 24 hours and verify they are in
Meditech by accessing the EMR (order
history section, sorted by date)
• Sign entire physician’s order sheet with
name/initials, title, date and time in red
ink
44. Blood Administration
Documentation
• Blood Transfusions are documented as an Intervention
Set, which can be added using the “Add Intervention” link
on the Intervention worklist (search for “set”)
• The set is comprised of:
– Blood Administration Verification (completed just prior to starting
infusion)
– Blood Product Infusion (start time and initial rate)
– Infusion Changes (any rate changes during infusion)
– Blood Product Completion (completed at end of infusion)
– Blood Vital Signs (baseline vitals taken at start, then q15min x 2
after initiation, then hourly)
45. Documentation of Wounds
• Wounds are documented as an Intervention Set,
which can be added using the “Add Intervention”
link on the Intervention worklist (search for “set”)
• The set is comprised of:
– Wound / Pressure Ulcer Status Assessment: for initial,
weekly, and change of status wound documentation
(more detailed)
– Wound Care / Dressing Change Assessment: for daily
documentation of dressing changes (focused
assessment specifically for dressing changes)
46. Critical Lab Values
Documentation
• The lab will call the nurse (as well as the
physician) responsible for taking care of the
patient with the critical lab value
• The telephonic critical result, upon receipt, will
be read back to the technologist/technician and
documented as having been read back. If that
does not happen, the technologist/technician will
request that the nurse receiving the critical result
read it back.
47. Critical Lab Values
Documentation
Procedure
1. Verify the result by verbally reading the result
back to the technologist/technician
2. Notify the nurse assigned to the patient of the
critical result if she/he was not the one to
receive the telephonic notification.
3. Document receiving the phone call about the
critical value, the critical result, and what you
did about the result on the Critical Lab Values
Intervention in Meditech PCS.
48. Computer Downtime
• In the event of a computer downtime, the
documentation system reverts back to paper (all
paper forms will be stocked on units)
• For downtime less than 4 hours (med/surg) and 2
hours (critical care), information that is recorded on
paper will need to be entered into PCS
• For downtime exceeding 4 hours (med/surg) and 2
hours (critical care), the paper system will replace
PCS until the end of the shift and until the system is
back up – the only data that must be re-entered into
PCS in this case are the Vital Signs and the I&O, so
the EMR record will be accurate
49. Discharge Documentation
• The physician writes the discharge instructions
• The nurse is responsible for reviewing all instructions
with the patient and obtaining the patient signature
• Carenotes can be printed out from the Infoweb (click on
Micromedix link to access) for patient education
• The nurse should make sure the patient understands the
complete list of medications the patient is to take once
being discharged (compared to any medications the
patient was taking on admission), as part of the
medication reconciliation process
• Original form goes to medical records and a copy is
given to the patient upon discharge
50. What stays on paper?
• Consent forms
• Admission / Transfer Summaries
• OR/Recovery Documentation
• Physician Order Sheets
• Documentation During Patient Codes
• Pre-op Checklist
• Discharge Instructions
• Labor Event – Triage up until Delivery
• Monitoring Strips
51. Documentation Details
• A nurse can skip a question on an
assessment if he/she is unable to assess
the question due to patient condition or if
the question is not applicable for the
patient at that time
• Any retrospective documentation can be
entered up to 3 days following patient
discharge. ?
52. Documentation Details
• Changes to documentation may only be
made by the person who recorded the
documentation
• Partially documented entries,
documentation editing, and undoing
documentation can be completed by
clicking in the History column for the
appropriate intervention
53. SYSTEM OF MEDICAL RECORD
• DEFINITION
Medical Record of the patient stores the
knowledge concerning the patient and his care. It
contains sufficient data written in sequence of
occurrence of events to justify the diagnosis,
treatment and outcome.
In the modern age, Medical Record has its utility
and usefulness and is a very broad based
indicator of patients care.
54. Flow of Medical Record :-
The flow chart of inpatient Medical Record is as
under :-
Wards
Central Admission
Office
Medical Record Department
1. Assembling Afetr completion of
Reccords
2. ADMN. &
Hospital statistics prepared
Discharge Monthly/Yearly
analysis
3. Storage Area Medical Record is filled for perusal of
Patients/claims/research purposes.
55. FILING OF MEDICAL RECORDS
• The inpatients Medical Record is filed by the
serial numbers assigned at central Admitting
Office.
• The Record is bound in bundles 100 each
and are kept year wise according to the serial
number.
RETENTION OF MEDICAL RECORD
• The policy is to keep indoor patient Records
for 10 years
• The OPD registers for 5 years
• The record which is register for legal
purposes in Maintained for 10 years or till
final decision at the court of Law.
56. TYPES OF RECORDS
1. Cumulative or continuing records
• This is found to be time saving, economical and also it is helpful to review the total history of an individual
and evaluate the progress of a long period. (e.g.) child’s record should provide space for newborn, infant
and preschool data.
• The system of using one record for home and clinic services in which home visits are recorded in blue and
clinic visit in red ink helps coordinate the services and saves the time.
R S MEHTA, MSND 56
57. 2. Family records
• The basic unit of service is the family. All
records, which relate to members of family,
should be placed in a single family folder. This
gives the picture of the total services and helps
to give effective, economic service to the family
as a whole.
• Separate record forms may be needed for
different types of service such as TB, maternity
etc. all such individual records which relate to
members of one family should be placed in a
single family folder.
R S MEHTA, MSND 57