Hospital records are broadly classified into four categories: patient clinical records, individual staff records, ward records, and administrative records. Common record forms include admission nursing history forms, flow sheets, graphic records, patient care summaries, standardized care plans, progress notes, and discharge summary forms. The most common documents in a patient's record are the admission sheet, physician's order sheet, nurse's admission assessment, graphic/flow sheets, medical history and examination, nurses' notes, medication records, progress notes, and diagnostic test results.

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:
1. Patients clinical record
2. Individual staff records
3. Ward records
4. 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
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.

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.

12. 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.

13. • 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.

14. 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.

15. 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

16. 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.

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

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

19. 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

20. 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

21. COMPUTERIZED
DOCUMENTATION

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

23. 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.

24. 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.

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