Types of records and common record keeping forms & computerized documentation

Types of records and common record keeping forms & computerized documentation

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  Types Of RecordsAnd Common Record Keeping Forms By: Mr. M. Shivananda Reddy
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  TYPES OF RECORDS Hospitalrecords are broadly classified into four categories based on the area of usage. They are: 1. Patients clinical record 2. Individual staff records 3. Ward records 4. Administrative records with educational value.
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  PATIENTS CLINICAL RECORDS Itis 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 a) Scientific and legal b) Evidence to the patient the his /her case is intelligently managed. c) Avoids duplication of work. d) Information for medical and legal nursing research. e) Aids in the promotion of health and care. f) Legal protection to the hospital doctor and the nurse.
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  • Examples: • Physician’sorder 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
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  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
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  WARD RECORDS. These arethe 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
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  ADMINISTRATIVE RECORDS WITH EDUCATIONALVALUE. • Treatment register. • Admission and discharge register. • Personnel performance register. • Organogram / organization chart • Job description • Procedure manual
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  Common Record KeepingForms
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  • A varietyof 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
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  Admission Nursing HistoryForms • 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.
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  Flow Sheets andGraphic 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.
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  • flow sheetshelp 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.
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  Patient Care Summaryor 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.
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  The patient caresummary 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
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  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.
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  Progress Notes • Progressnotes made by nurses provide information about the progress a client is making toward achieving desired outcomes.
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  Discharge Summary Forms Dischargedocumentation includes • Medications • Diet • Community resources • Follow-up care • Who to contact in case of an emergency or for questions
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  ACUITY RECORDS • Althoughacuity 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
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  Most Common DocumentsIn 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
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  COMPUTERIZED DOCUMENTATION
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  Computerized documentation • Nursesuse computers to store the client’s database, add new data, create and revise care plans, and document client progress.
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  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.
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  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.
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  Precautions during Computerized charting •Password. Never share. Change frequently. • Make sure terminal cannot be viewed by unauthorized persons.