HEALTH RECORD AND

DOCUMENTATION

PREPARED BYMRS/ HAMDIA MOHAMMED

Learning objectives:-1. Introduction.2. Define health record.3. Explain types of health record.4. Mention purposes of health record.5. List general guideline for recording.

Introduction

Health

personal

communicat

ion

RecordDiscussion

Report

1- Definition of health record.

An electronic health record (EHR) (also electronic patient record (EPR) or computerized patient record) is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations

Types of health record.

Health records take many forms and can be on paper or electronic.

* Different types of health record include:-

1- Hospital admission records: This including in.Patient’s demographics data ( Name,

age and sex) .

Address.

Occupation.

Marital status.

Religion.

Patient’s problem ( the reason for admitted to hospital).

past medical history (If patient have any chronic health conditions, such as diabetes or asthma,…) .

Physical assessment for body system.

If patient have any allergies from currently taking medication or previously had any adverse reactions to certain medications,

The treatment that patient will receive.

Height and weight.

2- Hospital discharge records : which will include the results of

treatment and whether any follow-up

appointments or care are required.

Flow Sheet:- it enables nurses to record nursing data quickly , concisely and provides an easy-to-read record of the client’s condition over time.

3- Graphic Record : this record typically indicates body temperature, pulse, respiratory rate, blood pressure .

4- Fluid Balance Record : all routes of fluid intake and all routes of fluid loss or output are measured and recorded on this form.

5- Medication Administration Record: medication flow sheets usually include

designated areas for the date of the medication order , medication name and dose, the frequency of administration and route and the nurse’s signature.

6- Skin Assessment Record: a skin or wound assessment is often

recorded on a flow sheet. These records may include categories related to stage of skin injury, drainage, color, odor, and treatment.

7- Progress Notes : it made by nurses provide information about the progress a client is making achieving desired outcomes.

- Progress notes include information about client problems and nursing interventions.

8- Laboratory, x ray and radiology report .

Ensuring Confidentiality of computer record:- Personal password.

Never leave the computer terminal unintended.

Don’t leave client information displayed on the monitor.

healthcare records is to record important clinical information, which may need to be accessed by the healthcare professionals involved in patient care.

1- Communication:Patients record prevent.• Fragmentation .• Repetition .• Delay in patient care.

Purposes of health records

Purposes of health records Cont.

2- Planning client care.

3- Auditing health agencies. An audit is a review of client

records for quality assurance purposes.

4- Research.

Purposes of health records Cont.5- Education.

6- Legal documentation.

7- Health care analysis.

8- Reimbursement. Documentation helps a facility

receive reimbursement from government

General guideline for recording:

1- Date and time.2- Legibility.3- Permanence.4- Accepted terminology.5- Correct spelling.6- Signature.

8- Accuracy.9- Sequence.10- Appropriateness.11- Conciseness.12- Preferable abbreviations.13- Completeness.