According to Health and medicine slide share, Reddy, (2015), Brar,(2015) hospital records are broadly classified into

four categories based on the area of usage. They are:

1. Patients clinical record
2. Individual staff records
3. Ward records
4. Administrative records with educational value.
PATIENTS CLINICAL RECORDS
It is the knowledge of events in the patient illness, progress in his or her recovery and the type of care given by the
hospital personnel. These are Scientific and legal, evidence to the patient that his /her case is intelligently managed.
Avoids duplication of work. Information for medical and legal nursing research. Aids in the promotion of health and
care. Legal protection to the hospital doctor and the nurse.
• Examples: • Physician’s order sheet • Nurse’s admission assessment • Graphic sheet and flow sheet- vital signs, I/O
chart • Medical history and examination • Nurses’ notes • Medication records • Progress notes
INDIVIDUAL STAFF RECORDS.
A separate set of record is needed for each staff, giving details of their sickness and absences, their carrier and
development activities and a personnel note
 WARD RECORDS.
These are the records pertaining to a particular ward. • Circular record • Round book • Duty roaster • Ward indent
book • Ward inventory book • Staff patient assignment record • Student attendance and patient assignment record
 ADMINISTRATIVE RECORDS WITH EDUCATIONAL VALUE. •
Treatment register. • Admission and discharge register. • Personnel performance register. • Organogram /
organization chart • Job description • Procedure manual
Common Record Keeping Forms
• A variety of paper or electronic forms are available for the type of information nurses routinely document. • The
categories within a form are usually derived from institutional standards of practice or guidelines established by
accrediting agencies
 Admission Nursing History Forms •
1. A nurse completes a nursing history form when a patient is admitted to a nursing unit. • The form guides the nurse
through a complete assessment to identify relevant nursing diagnoses or problems.
2.11. Flow Sheets and Graphic Records • Flow sheets allow you to quickly and easily enter assessment data about a
patient, including vital signs and routine repetitive care such as hygiene measures, ambulation, meals, weights, and
safety and restraint checks.
3.12. • flow sheets help team members quickly see patient trends over time and decrease time spent on writing
narrative notes. • Critical and acute care units commonly use flow sheets for all types of physiological data.
4.13. Patient Care Summary or Kardex Kardex forms have an activity and treatment section and a nursing care plan
section that organize information for quick reference. An updated Kardex eliminates the need for repeated referral to
the chart for routine information throughout the day.
5.14. The patient care summary or Kardex includes the following information: • Basic demographic data (e.g., age,
religion) • Health care provider’s name • Primary medical diagnosis • Medical and surgical history • Current orders
from health care provider (e.g. dressing changes, ambulation, glucose monitoring) • Nursing care plan • Nursing
orders (e.g., education sessions, symptom relief measures, counseling) • Scheduled tests and procedures • Allergies
6.15. Standardized Care Plans • Some institutions use standardized care plans. • The plans, based on the institution’s
standards of nursing practice, are pre-printed, established guidelines used to care for patients who have similar health
problems. • After completing a nursing assessment, the nurse identifies the standard care plans that are appropriate for
the patient and places the plans in his or her medical record. • The nurse modifies the plans to individualize the
therapies.
7.16. Progress Notes • Progress notes made by nurses provide information about the progress a client is making
toward achieving desired outcomes.
8.17. Discharge Summary Forms Discharge documentation includes • Medications • Diet • Community resources •
Follow-up care • Who to contact in case of an emergency or for questions
9.18. ACUITY RECORDS • Although acuity records are not part of a patient’s medical record, they are useful for
determining the hours of care and staff required for a given group of patients. • A patient’s acuity level, usually
determined by a computer program, is based on the type and number of nursing interventions required over a 24-hour
period. • The patient-to-staff ratios established for a unit depend on a composite gathering of 24-hour acuity data
. Most Common Documents In Patient Record: • Admission sheet • Physician’s order sheet • Nurse’s admission
assessment • Graphic sheet and flow sheet- vital signs, I/O chart • Medical history and examination • Nurses’ notes •
Medication records • Progress notes • results from diagnostic tests (e.g., laboratory and x-ray film results) • consent
forms • Discharge summary • Referral summary
COMPUTERIZED DOCUMENTATION
Computerized documentation • Nurses use computers to store the client’s database, add new data, create and revise
care plans, and document client progress.
 Computerized charting- advantages – Increases the quality of documentation and save time. – Increases legibility and
accuracy. – Facilitates statistical analysis of data. – The system links various sources of client information.
Computerized charting- disadvantages • Client’s privacy may be infringed on if security measures are not used. •
Breakdowns make information temporarily unavailable. • The system is expensive. • Extended training periods may
be required when a new or updated system is installed.
 Precautions during Computerized charting • Password. Never share. Change frequently. • Make sure terminal cannot
be viewed by unauthorized persons.
https://www.slideshare.net/sivanandareddy52/types-of-records-and-common-record-keeping-forms-
amp-computerized-documentation retrieved on 14th January 2021.

Cleveland, A., & Cleveland, D. (2013). Introduction to Indexing and Abstracting: Fourth Edition. Santa Barbara: ABC-CLIO.

aspects of costs that change substantially, in practice organizations

Gollins et al.,(2014) states that
cannot afford to keep up everything hence a challenge. The the transition to the digital environment
means that the traditional reliance on retrieval and access tools will not work. Tools that can extract
and confer meaningful structure on large corpora of digital records based not only on topic matter, but
also on the context of creation and distribution will be essential, this presents a new set of significant
and interesting challenges for information retrieval.

The case of sensitivity review, while the nature of a sensitivity can be described (e.g. personal
privacy), the specific features that will render the record sensitive are generally unknown to the
reviewer in advance. This is because such sensitivities are not only conferred by the content of the
record (the topics and entities) but also by the context of creation and distribution this makes it
challenging to retrieve these particular records due to inadequate information on the retrieval and
access tools

Gollins, T., McDonald, G., Macdonald, C., & Ounis, I. (2014, January). On using information retrieval for the
selection and sensitivity review of digital public records. In PIR@ SIGIR.

According to Egwunyenga, (2009)These challenges might prevent the institution from enjoying the benefits of
proper record managements such as effective retrieval; tracing; supervision and monitoring of documents.

Difficulty inventorying and tracking files. Keeping track of matter files in boxes is difficult, the access
and retrieval tool creation process needs to be simple. Otherwise, the records staff won’t use it properly.

Egwunyenga, E. J. (2009). Record keeping in universities: Associated problems and management options in
South West Geo-Political Zone of Nigeria. International Journal of Educational Sciences, 1(2), 109-113.