 1.

communication with other healthcare

professionals
 2. recording of therapeutic and diagnostic
orders
 3. care planning
 4. quality-of-care recording
 5. research
 6. decision analysis
 7. education
 8. legal documentation
 9. reimbursement
 10. Historical documentation
 Admitting Area-ER/OPD
• Admission date, time and room/bed number of
patients.
• Mode of admission, such as, ambulatory, by
wheelchair, by stretcher, etc.
• Vital signs:
❖Blood Pressure (BP)
❖Level of consciousness
❖Pulse Rate (PR)
❖Respiratory Rate (RR)
 ❖Temperature
❖Height
❖Weight
➢ Admission notes, the latest version is FOCUS
charting
➢ The observed disposition of valuables
endorsed for safe keeping
➢ The admitting physicians
➢ Written (orders) prescriptions of physicians
➢ Medications given: date, time, dosage and
route
Specimen(s) obtained :
- type of specimen(s)
- time it was obtained
- time it was submitted to the laboratory
with signature who submitted and received
the specimen. This will prevent loss or
misplace of specimen.
➢ Status of patient during transfer to other
patient areas.
 In-Patient Areas
❖ time of doctor’s visit and all subsequent
visits of the physician
❖ written orders of all physicians
❖ Specimen(s) obtained:
- type of specimen (s)
- time it was obtained
- time it was sent to the laboratory
➢ Reactions, attitudes, moods and status of the
patient
❖Pertinent subjective observation
- complaints of pain
- discomforts or other attitudes
- state of depression : worry, agitation,
reaction to hospitalization or illness