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RECORD
KEEPING
Medical
records exist for the benefit of the patient and for reference
by future health care providers. If your hospital’s policy
is for records to stay at the hospital rather than being kept
by patients, it is essential that they are well maintained and
organized for future reference. This requires well trained staff
as well as secure and dedicated space.
Records are confidential and should be available only to people
involved directly in the care of the patient.
Even if your hospital maintains records, each patient should
receive a written note of any diagnosis or procedure performed.
If a woman has had a ruptured uterus, for example, it is essential
that she knows this so that she can communicate this information
to health care providers in the future.
Clinical notes are an important means of communication for the
team involved in a patient’s care by documenting the management
plan and the care offered; they can also be used to improve
patient care when reviewed as part of an audit. Notes may also
be requested for insurance and medico-legal purposes.
All members of the health care team are responsible for ensuring
that records are:
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Complete |
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Accurate |
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Legible
and easily understood |
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Current,
written at the time of patient contact, whenever possible |
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Signed,
with the date, time, name and position of the person making
the entry. |
Once written, notes must not be changed; a subsequent entry
can be made if there is a change in the patient’s condition
or management.
Admission note/preoperative note
The preoperative assessment should be documented, including
a full history and physical examination, as well as the management
plan and patient consent.
Operating room records
Operating room records can be kept in a book or can be kept
as separate notes on each procedure. Standardized forms save
time and encourage staff to record all required information.
A theatre record usually includes:
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Patient
identity |
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Procedure
performed |
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Persons
involved |
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Complications |
By
looking at records of all procedures, a hospital can evaluate
occurrences such as complications and postoperative wound infections
or review the type and number of procedures being performed.
Such evaluation, which should be the regular duty of one member
of the hospital team, permits assessment of the application
of aseptic routine within the hospital and allows for future
planning.
Delivery book
The delivery book should contain a chronological list of deliveries
and procedures, including interventions, complications and outcomes.
It may contain some of the same information that would be included
in a theatre record.
The operative note
After a surgical procedure, an “operative note”
must be written in the patient’s clinical notes. Include
orders for postoperative care with your operative note.
Postoperative note
All patients should be assessed at least once a day, even those
who are not seriously ill. Vital signs should be taken as dictated
by the patient’s condition and recorded; this can be done
on a standard form or graph and can also include the fluid balance
record. Progress notes need not be long, but must comment on
the patient’s condition and note any changes in the management
plan. They should be signed by the person writing the note.
Notes can be organized in the “SOAP” format:
| Subjective |
How
the patient feels |
| Objective |
Findings
on physical examination, vital signs and laboratory results |
| Assessment |
What
the practitioner thinks |
| Plan |
Management
plan; this may also include directives which can be written
in a specific location as “orders”. |
A consistent approach such as this ensures that all areas are
included and that it is easy for other members of the team to
find information.
See Unit 3: The Surgical Patient for more detailed guidance
on preoperative, operative and postoperative notes.
Discharge note
On discharging the patient from the ward, record:
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Admitting
and definitive diagnoses |
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Summary
of patient’s course in hospital |
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Instructions
about further management as an outpatient, including any
medication and the length of administration and planned
follow-up. |
Standard
operating procedures
Create and record standard operating procedures for the hospital.
These should be followed by all staff at all times. Keep copies
of these procedures in a central location as well as the place
where each procedure is performed so they are available for
easy reference.
Interhospital communication
Each patient who is transferred to another hospital should be
accompanied by a letter of referral which includes:
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Patient
identity |
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Name
and position of the practitioner making the referral |
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Patient
history, findings and management plan to date |
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Reason
for referral.
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