Maintaining Patient Records

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Maintaining Patient Records

• By
• Nancy Knight

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The Patients Chart

• Is a record of the care provided to the patient.
• Is a legal document and may be used in a court of
  law.
• Is considered privileged communication.
• Is the property of the healthcare provider but
  the patient should have complete access to any
  information in the record.
• Must be maintained for a certain length of time
  required by state law.

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Rules of Charting

• May be electronic, but measures must be in place
  to maintain confidentiality of the record.
• Secure passwords
• Limiting personnels access to certain documents
• Using codes to limit access to certain
  information
• Monitoring and evaluating computer use
• Time outs when computer is not in use
• Being aware of shoulder surfing and other
  inadvertent access

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Rules of Charting

• Must be maintained as confidential record with
  limited access
• Must be written in ink (often color-coded per
  shift)
• Erasures are not allowed.
• Errors are crossed through with a single line so
  that the information is still readable and then
  initialed by the person making the change.

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Rules of Charting

• Entries in records such as nurses notes or
  progress notes must be in appropriate time
  sequence therefore entries must be made in a
  timely manner.
• All entries should be signed.
• Records are usually filed with the most recent
  documents first.
• When records are destroyed, after the legal time
  for retention, they must be shredded or burned.

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Standard Chart Forms

• Statistical Data Sheet
• History Sheet
• Physical Sheet
• Progress Notes
• Physicians Orders
• Nurses Notes
• Medication Administration Record
• Vital signs graphic record
• Diagnostic Reports
• Discharge Summary

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Standard Chart FormsStatistical Data Form

• Contains the demographic information of the
  patient such as name, age, sex, date of birth,
  address, phone, emergency contact information,
  and insurance information
• Usually developed by admission/business services
  but may need to be edited by unit secretary as
  necessary

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Standard Chart FormsHistory and Physical

• This document may be separate or together and is
  the responsibility of the physician to record.
• History records the history of the present
  illness as well as the past medical history of
  the patient and family medical history.
• Physical Exam records the current findings of
  the physical examination of the patient,
  including a review of all body systems in a
  cephalocaudal order.

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Standard Chart FormsProgress Notes

• This record is the documentation by the physician
  of brief reports regarding the progress and
  prognosis of the current illness after each
  examination of the patient.

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Standard Chart FormsPhysicians Orders

• Physicians must give admission orders for a
  patient to be admitted to the facility
• It describes the care that the patient is to be
  given including but not limited to activity,
  diet, medication, diagnostic test, treatments,
  consultations, etc.
• The unit secretary will be responsible for
  putting these orders into action by the
  appropriate team member or department.

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Standard Chart FormsNurses Notes

• Documents the care provided to the patient by the
  nursing staff
• Document observations made by nursing personnel
• Licensed nurses are responsible for recording
  this data on the chart.

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Standard Chart Forms

• Medication Administration Record Is a summary
  sheet to record the administration of routine
  medications
• Vital Signs Graphic Record is a graphic
  recording of routine vital signs

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Standard Chart FormsDiagnostic Reports

• This may be a section of the chart rather than a
  specific form. This is where reports from
  different diagnostic evaluations will be kept in
  the chart. It includes such reports as
• Radiology reports
• Laboratory reports
• Pathology reports
• Physical therapy evaluations/services
• Respiratory therapy evaluations/services

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Standard Chart FormsDischarge Summary

• Document recorded by the physician that
  summarizes the course of the hospital stay, the
  patients condition at discharge and includes
  plans for future treatment and/or any needed
  follow-up with anticipated prognosis.

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Special Chart Forms

• These are chart documents that are generated
  depending on the services that the patient
  receives.
• They are not a part of every patients record but
  are commonly seen in patients charts
• They are created by the deptartment or person
  delivering the service.
• The unit secretary would be responsible for
  seeing that they are filed in the chart in the
  appropriate section.

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Special Chart Forms

• Operative Report
• Special Procedure Reports
• Consultation Letter or Request
• Permission forms for certain procedures
• Intake and output records

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Maintaining the Patients Chart

• Unit secretarys responsibility is
• to create the chart upon admission
• Make sure that forms have available space for
  documentation or new forms added
• File documents in the chart in their appropriate
  sections
• Maintain charts in their appropriate place so
  that they are always available when needed by
  various personnel
• Transcribe physicians orders (put the order into
  action)