NCM 103a: Fundamentals of Nursing (RLE)

Topic: Client’s Record/Patients Chart

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Client’s Record/Patient’s Chart
 is a formal, legal document that provides evidence of a client’s care.
 is a complete record of a patient’s key clinical data and medical history, such as
demographics, vital signs, diagnoses, medications, treatment plans, progress notes,
problems, immunization dates, allergies, radiology images, and laboratory and test
results.
 Only the patient and the health care providers directly involved in her or his care can
view a medical chart
 The medical chart belongs to the patient, and she or he has the right to make sure the
charts are accurate

Purposes
1. Communication
o Serves as a vehicle by which different health professionals who interact with a
client communicate with each other
o This prevents fragmentation, repetition, and delays in client care
2. Planning client care
o Nurses use baseline and ongoing data to evaluate the effectiveness of a nursing
care plan
o Each professionals uses data from the client’s record to plan care for the client
3. Auditing health agencies
o An audit is a review of client records for quality assurance purposes
o Accrediting agencies (such as JCAHO) may review client records to determine if a
particular health agency is meeting its stated standards
4. Research
o The information contained in a record can be a valuable source of data for
research
o The treatment plans for a number of clients with same health problems can
yield information helpful in treating other clients
5. Education
o Students in health disciplines often use client records as educational tools.

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 o A record can frequently provide a comprehensive view of the client, the illness,
effective treatment strategies, and factors that affect the outcome of the illness
6. Reimbursement
o Documentation also helps a facility receive reimbursement from the government
o The client’s record must contain the correct diagnosis-related group (DRG)
codes, which reveals that the appropriate care has been given. This will enable
the facility to obtain payment through Philhealth, or from insurance companies
and other third-party payers.
o Accurate, thorough recording by nurses will facilitate reimbursement from these
agencies
7. Legal documentation
o The client’s record is a legal document and is usually admissible in court as
evidence
o It may be considered inadmissible as evidence when the client objects, because
the information the client gives to the physician is confidential
8. Health care analysis
o Information from records may assist health care planners to identify agency
needs, such as over utilized or underutilized hospital services
o Records can be used to establish he costs of various services and to identify
those services that cost the agency money and those that generate revenue

Components of Patient’s Chart

 Admission (face) sheet
o Legal name, birthdate, age, gender
o Social security number
o Address
o Marital status; closest relatives or person to notify in case of emergency
o Date, time, and admitting diagnosis
o Food or drug allergies
o Name of admitting (attending) physician
o Insurance information (if any)
o Any assigned diagnosis-related group (DRG
 Physician’s Order Sheet
o Record of physician’s orders for treatment and medications, with date, time and
physician’s signature
 Nurse’s Admission Assessment

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 o Summary of nursing history and physical assessment

 Graphic Sheet and Flow Sheet

o Record of repeated observations and measurements such as vital signs, daily
weights, and intake and output
 Medical History and Examination
o Results of initial examination performed by physician, including findings, family
history, confirmed diagnosis, and medical plan of care
 Nurses’ Notes
o Narrative record of nursing process: assessment, nursing diagnosis, planning,
implementation, and evaluation of care
o FDAR, SOAPIE
 Medication Records
o Accurate documentation of all medications administered to client: date, time,
dose, route, and nurse’s signature
 Physician’s Progress Notes
o Ongoing record of client’s progress and response to medical therapy and review
of the disease process
 Health Care discipline’s records
o Entries made into record by all health-related disciplines: radiology, social work,
and laboratories
 Discharge summary
o Summary of client’s condition, progress, prognosis, rehabilitation, and teaching
needs at time of dismissal from hospital or health care agency

Prepared by:
NCM 103a Fundamentals (Skills) Lecturers

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