| Unit 18 Medical Document Writing Chapter 1 Recording and Management of Medical Record Reasons for Records Communication The record is the vehicle by which members of the health team communicate. Although health team members also communicate orally, the record is efficient and permanent. Assessment The information from patient records can help nurses anticipate and plan for future needs, help indicate the patient’s health problems, make nursing plans, and choose nursing interventions. Research The information in records can be a valuable research tool. For example, researchers may study the treatment plans for a number of patients with the same illness to ascertain which plan might be of greatest benefit to a particular patient. Education Students in various health disciplines use patient records as tools in education. A record frequently provides a comprehensive view of the patient, the illness, and the assistance provided. Medical records are used to educate nurses, physicians, dietitians, and people in most of the health disciplines. Legal documentation The patient’s record is a legal document that is admitted in court as evidence. In some jurisdictions, the record is not admitted as evidence if the patient objects on the grounds for such evidence violates the confidentiality of the physician-patient relationship. Statistics Statistic information from patient records can help an agency anticipate and plan for future needs. Guidelines for Recording Accuracy All data recorded must be accurate and specific. Notation of time is an important part of accuracy. In some settings, time is recorded according to the 24-hour clock (military clock). Correct spelling Spelling is important to accuracy. Two decidedly different medications may have similar spellings, for example, Digoxin and Digitoxin. Legibility All recording must be legible. Records are normally kept in ink because pencil does not provide a permanent record. Black ink may be required for photocopying purposes. Print or script writing is acceptable. Correcting an error in charting is discussed later in this chapter. Brevity Recordations should be brief, yet all pertinent data must be included. Extra words, such as the patient’s name and the ward, should be omitted, since the patient’s identity is obvious. Correct terms and acceptable abbreviations and symbols are used. Management of Medical Record Admission sheet includes biographical and insurance information about the patient and the family (and the discharge date and diagnosis, after the patient leaves the hospital), also known as the face sheet. Items include in the medical record: ● Record of entering the hospital. ● Homepage of medical record of in-patient. ● Medical record of out-patient. ● Physician’s orders Include diet, activity level, medications, treatments, laboratory tests, x-rays. ● Physician’s progress record ● Patient history and physical examination Done by the admitting physician. ● Patient care record or nursing notes ● Records of any consultations ● Graphic sheets Detailed records of temperature, pulse, respirations and blood pressure. ● Medication sheet Lists all medications ordered and given. ● Laboratory reports Include all tests ordered and results. ● X-ray reports and reports of other diagnostic tests Include interpretation of those examinations by specialists (such as radiologists). ● Flow sheets Routine daily cares, BMs, activity, diet, etc. ● Operating reports describing any surgery done Include anesthesia, pathology, and PAR (postanesthesia recovery room) reports, as well as detailed graphic records made during and immediately following the surgery. ● Intake and output records and records of any intravenous fluids given: Include records of blood transfusions, tube feedings, and TPN (total parenteral nutrition). ● Physician’s note or discharge summary, and the record of the discharge plan Include home care, referrals, and date of next appointment for examination. All medications or prescriptions sent home with the patient are noted. Chapter 2 Medical Record Writing Medication Orders The medical record is a written report on the findings, treatment, and progress of the patient, which is seen in a doctor’s office, a clinic, an emergency room, or as a hospital patient. Medications ordered are a part of the record. Types of medication orders ● A stat order indicates that the medication is to be given immediately and only once. Stat orders indicate that the order has top priority and the medication must be administered usually in 10 minters, e.g., Demerol 100 mg IM stat. ● The single order is for a medication to be given once at a specified time usually in 24 hours, e.g., Seconal 100 mg h.s. before surgery. ● The standing order may or may not have a termination date. A standing order may be carried out indefinitely (e.g., multiple vitamins daily) until an order is written to cancel it, or they may be carried out for a specified number of days (e.g., Demerol 100 mg im q4h. × 5 days). ● A p.r.n order permits the nurse to give a medication when in her or his judgment the patient requires it, e.g., Amphojel 15 ml p.r.n. PRN medications are given less frequently, in response to a patient’s request or when the need is indicated. The orders continue in effect for over 24 hours. It is of no effect until they are stopped. ● A s.o.s order is effective in 12 hours, which is used when necessary. It will be ineffective if not used. The nurse must use good judgment as to when the medication is need招生簡(jiǎn)章ed and when they can be safely administered. Essential parts of the medication orders● Full name of the patient Use of the full name avoids the danger of confusion with another patient having the same surname. Oftegydjdsj.org.cn/sanji/n the patient’s room number is also included. ● Date and time of day Date and time tell when the order is to be started. If the order is for a specified number of days, it also tells when the order is to be discontinued. ● Name of the drug The use of the generic name is preferred to the trade name. ● Dosage of the drug Usually it is stated in the metric system (gram, ml). Other systems may be used as well, depending on the system used in the hospital. ● Time and frequency of dose The hospital nursing service usually determines the time schedule for drug routines. For instance, for drugs to be given every 4 hours, one hospital may choose the even-numbered hours, another may choose the odd. ● Method of administration Usually it is understood that the oral method is to be used if no other method is specified, although “oral” should be specified, to prevent any misunderstandings. ● Physician’s signature This is essential for legal reasons or if there is some question about the order, an unsigned order may mean that the physician had not finished writing it. Transcribing orders ● Read all orders! Always do stat orders first! ● Order the medication from the pharmacy, giving the name of the drug, dose, administration, and frequency of administration. ● Write the information on the Kardex card. Most institutions have a policy that all antibiotics, anticoagulants, hypnotics, and narcotics must be reordered every 48 hours. ● Make out a medication card. Stat orders may be written on a special form or on a card of different color. Enter patient’s name and room number, name of medication, dosage, and route of administration. Enter the date of the order and the date to be discontinued, if known. ● Enter the medication, dose, and times on the medication record of the chart. ● Notify the person giving medications. ● Make appropriate notations on the doctor’s order sheet signifying you have transcribed the order. Generally, a line is drawn in red under the last order and the physician’s signature, and the nurse signs the order sheet. ● When the medication is discontinued: Cross out the items on the Kardex Notify the nurse involved Destroy the medication card Make out drug credit if there are remaining medications Mark “DC” on the medication sheet of the chart Mark appropriate notations on the doctor’s order sheet. ● Ask the doctor if you have any questions. | 
