Part 2
Types of records___
1. Patient clinical records
2. Medical /Nursing records
3. Ward records
4. Administrative records
Patient clinical record
It is the knowledge of involved in the patients illness progress in his recovery and the type of care provided by the hospital personnel. All records basically contain the following information ______
1. Client's identification and demography data.
2. The present complaints
3. Informed content for treatment and procedures
4. Admission nursing history
5. Family history
6. Physical examination findings
7.Nursing diagnosis and problems
8. Nursing care plan
9. Medical history
10. Tentative diagnosis
11. Medical diagnosis
12. Therapeutic orders
13. Treatment given
14. Reports of diagnostic studies
15. Final diagnosis
16. Client education
17. Summary of operative procedures
18. Discharge plan and summary
19. Any specific special instruction
Medical records
Medical record is a legal document providing information of a patient medical history and data by physician , nurse practitioner and other members of the health care.
Some information contained in the medical records____
Identification information of the patient .
Patient health is information on a patient tell the health care providers about their past and present health status.
Medical examination findings.
Nursing records
Progress notes :- it should be written at least once every 24 hours and for each of the following events.
a) Admission
b) Transfer
c) Discharge
d) Treatment or procedure
e) Charge in patients condition.
f) Patient incident note.
g) Patient or parent /caregiver education.
Worksheet and kardexes :- nurse use worksheet to organise the care they provide and to manage their time and multiply priorities. Kardexes are used to communicate current orders , upcoming test or surgery is special clients for the use of aids for independent.
Flow sheets :- A new flow sheet is to be initiated for each 24 hours period , by signing and initiating the flow sheets the RN indicate.
A safety check has been performed the presence of correct ID band
The presence of an accurate allergy band.
The documentation of the monitor control number and assessment of appropriate alarm limits.
Intake/output section
Hourly IV site/ rate check.
Cumulative IV volume infused hourly.
Complete description of all IV solutions.
All medication given.
Vital signs section
Document vital signs in the space provided. Graph by the vital sign using the graph legend symbol and assessment legend.
Client care plan
Care plan outlines of the care for individual clients and make a part of the permanent health records.
Care plan written in ink , up-to-date and clearly identify the needs and wishes of the client
E - Health records
There is no doubt that the computerization of the health care records has many benefits . The same principle apply whether documentation is completed in the paper health care records or electronically.
Wards records
Ward records include ;-
Admission and discharge record
Line in record
Record of production or increasing beds.
Index books
Round book , attendance book and record book
Treatment records
Administration records
It includes record of______
Treatment
Admission
Equipment losses and replacement .
Personal performance
Organiszational records
No comments:
Post a Comment