Types Of Records And Common Record Keeping Forms

By:Mr. M. Shivananda Reddy

TYPES OF RECORDSHospital records are broadly classified into four

categories based on the area of usage. They are:

1. Patients clinical record2. Individual staff records3. Ward records4. Administrative records with educational

value.

PATIENTS CLINICAL RECORDSIt 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 legalb) 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.

• 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

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

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

ADMINISTRATIVE RECORDS WITH EDUCATIONAL VALUE.

• Treatment register.• Admission and discharge register.• Personnel performance register.• Organogram / organization chart• Job description• Procedure manual

Common Record Keeping Forms

• 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

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.

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.

• 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.

Patient Care Summary or KardexKardex 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.

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

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.

Progress Notes

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

Discharge Summary Forms

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

questions

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

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

COMPUTERIZED DOCUMENTATION

Computerized documentation

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

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.

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.

Precautions during Computerized charting

• Password. Never share. Change frequently.• Make sure terminal cannot be viewed by

unauthorized persons.