learning objectives:- 1. introduction. 2. define health record. 3. explain types of health record....
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HEALTH RECORD AND
DOCUMENTATION
PREPARED BYMRS/ HAMDIA MOHAMMED
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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.
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Introduction
Health
personal
communicat
ion
RecordDiscussion
Report
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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
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Types of health record.
Health records take many forms and can be on paper or electronic.
* Different types of health record include:-
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1- Hospital admission records: This including in.Patient’s demographics data ( Name,
age and sex) .
Address.
Occupation.
Marital status.
Religion.
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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.
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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.
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2- Hospital discharge records : which will include the results of
treatment and whether any follow-up
appointments or care are required.
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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.
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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.
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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 .
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Ensuring Confidentiality of computer record:- Personal password.
Never leave the computer terminal unintended.
Don’t leave client information displayed on the monitor.
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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
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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.
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Purposes of health records Cont.5- Education.
6- Legal documentation.
7- Health care analysis.
8- Reimbursement. Documentation helps a facility
receive reimbursement from government
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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.
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