Parts of the Patient’s Chart (Documenting)
and is usually admissible in court as
 Legally owned by the hospital
 Accurate and concise patient charting is an
important part of a nurse’s job.
 Through charting, nurses communicate vital
information to the entire healthcare team.
 A patient chart is also a legal document that
describes all aspects of a patient’s care,
Components of Patient’s Chart/ Medical Chart
 A discussion is an informal consideration of
a subject by two or more health care
personnel to identify a problem or establish
strategies to resolve a problem.
 A report is oral, written, or computer- based
communication intended to convey
information to others
 A record is written or computer based.
 A clinical record, also called a chart or client
record, is a formal, legal document that
provides evidence of a client’s care.
Purposes of Client Records
 Communication- The record serves as the
vehicle by which different health
professionals who interact with a client
communicate with each other.
 Planning Client Care- Each health
professional uses data from the client’s
record to plan care for the client
 Auditing Health Agencies- An audit is a
review of client records for quality-
assurance purposes
 Research- The information contained in a
record can be a valuable source of data for
research
 Education- Students in health disciplines
often use client records as records as
educational tool
 Reimbursement- For a facility to obtain
payment through Medicare,
 Legal Documentation- Is a legal document
evidences.
 Health care Analysis- Information from
records may assist health care planners to
identify agency needs, such as overutilized
and underutilized hospital services.
 Admission Sheet/ Top/ Face Sheet-
information include legal name, birth
details (date, year, place), age, gender,
address, contact number, parent’s basic
information, marital status, date, time
and admitting diagnosis, admitting
diagnosis, name of admitting and
attending physician
 Consent for Admission/ Management
Sheet - This page contains that the
patient or relatives allowing the
medical institution to take care their
patient (full decided) whether the
possible risk beyond on the process of
treatment course
 Patient’s Right Sheet - discusses the
patient’s right during the entire process
of medical treatment.
 Clinical History- contains initial history,
review of systems, and physical
assessment
 Vital Signs Graphic Chart- contains of
every shift 5 cardinal vital signs of the
patient
 Physician’s Order and Progress Notes-
Medical orders (diagnostics,
therapeutics and other health
management). Medical Observations,
treatments, client progress (Progress
Notes usually on the right corner side
of this sheet)
 Medication and Treatment Record-
name, dosage, frequency of the
medication and treatment on regular
intervals.
  PRN/ Premeds/ Nebulization-  Important data
separated sheet from the medication
 Vital signs must be recorded accurately and
and treatment record. As needed
promptly to provide continuous and current
medications, Pre medications (pre-
documentation.
operative, pre- blood transfusion) and
nebulization and inhalation  A record of a client’s vital signs helps
medications. providers diagnose and respond to the
 Venoclysis- documented on this sheet client’s changing condition.
all the Intravenous Fluids administered
to the patient.  The nurse needs to know the format for
 Vital Signs Monitoring- in detailed vital documenting vital signs in his or her agency.
signs monitoring of the patient (it Steps for recording vital signs in the paper
depends on the order of the physician, record include
or during blood transfusion monitoring Temperature - 36.5 – 37.5
[per ANSAP protocol on blood
transfusion management])  hyperthermia hypothermia
 Intake and Output Sheet- all routes of
Blood pressure – 120/60 mmhg (90/60)
fluid intake and all routes of fluid loss
of output are measured and recorded
on this form.  hypertension hypotension
 Laboratory Reports- all blood, urine
Pulse rate – 60 - 100 bpm
and stool exam results are attached on
this sheet. (
 Nurses Notes- pertinent assessment of  tachycardia bradycardia
client. Specific nursing care including  Radial, brachial, popliteal, dorsalis
teaching and client’s responses.
Respiratory rate – 12 – 20 bpm/cpm
 Consent for Procedures- all invasive
procedures prior to do so, must have a
written consent in relation that patient  tachypnea bradypnea
and relatives able to understand the
O2 – 95% - 100%
purpose of that procedure/s.
Pain scale – 0 – 10
Other Parts of Patient Chart (Per condition)
Plotting Vital Signs
 CBG monitoring sheet
 Patient’s discharge summary Time to Assess Vital Signs
 Discharge clearance
 Home against medical advice  On admission to health care agency to
obtain baseline data
Newborn Additional Parts  When a client has a change in health status
or report symptoms such as chest pain, or
 Immunization slip card
feeling hot or faint
 Newborn rooming and discharge checklist
 Before and after surgery or an invasive
 Newborn record
procedure
 EINC monitoring sheet
 Before and/ or after the administration of a
Vital Signs medication that could affect the respiratory
 or cardiovascular systems, for example,
before giving a digitalis preparation
 Before and after any nursing intervention
that could affect the vital signs (ambulating
a client who has been on bed rest)
The Graphic Record
 The graphic record is a flow sheet used
to easily document large amounts of
information for all members of the
healthcare team to read.
 Usually, the graphic record documents
measurements of vital signs, fluid
intake and output (I&O), weight, and
bowel movements, assessed at regular
intervals.
Recording Vital Signs
a. Locate the current date on the graphic record.
b. Record temperature by making a dot on the scale
parallel to the temperature value under the
designated time. Connect the dot to the previous
reading with a short line. (In many facilities using a
paper record, the temperature and pulse are
graphed in different color inks.)
c. Record pulse rate by making a dot on the scale
parallel to the pulse rate under the designated time.
Connect the dot to the previous reading with a short
line.
d. Record respiratory rate at the bottom of the graph
with numbers.
e. Record BP with written numbers (e.g., 120/80) or
graph the numbers in a manner similar to that used
for the temperature graph.
f. Record other information, such as weight, bowel
movements, and the totals for I&O, with written
numbers in the spaces provided.
Diagnostic Studies and Therapies
SKIN TEST: MANTOUX TEST
 PPD (Purified Protein Derivative) is used
 Route of administration: Intradermal
 Read 48 to 72 hours after injection
 (+) Mantoux test is induration of 10mm
or more
 For HIV positive clients, induration of
5mm is considered positive
 (+) Mantoux signifies exposure to
Mycobacterium tubercle bacilli
 Mantoux test will be positive for clients
who have received BCG
CHEST RADIOGRAPHY/ CHEST X-RAY
 In chest radiography, X-rays or
electromagnetic waves penetrate the
chest and cause an image to form on
specially sensitized film.
 Air appears radiolucent, whereas
normal tissue, bone, and abnormalities
— such as infiltrates, foreign bodies,
fluids, and tumors appear as densities
on the film.
 A chest X-ray is most useful when
compared with previous films to detect
changes
BRONCHOGRAPHY/ BRONCHOGRAM
 A radiopaque medium is instilled
directly into the trachea and bronchi
and the entire bronchial tree or
selected areas may be visualized
through x-ray
NURSING INTERVENTIONS BEFORE BRONCHOGRAM
 Secure written consent
 Check for allergies to sea foods or
iodine or anesthesia
 NPO for 6 to 8 hours
 Pre- op Medications: Atropine Sulfate
and Valium, topical anesthesia sprayed
into the throat; followed by local
anesthetic injected to the larynx
  Have oxygen and antispasmodic agents
ready
NURSING INTERVENTIONS AFTER BRONCHOGRAM
 Side- lying position
 NPO until cough and gag reflexes return
 Cough and deep breathe client
 Low grade fever is common
BRONCHOSCOPY
 The direct inspection and observation
of the larynx, trachea and bronchi
through a bronchoscope
DIAGNOSTIC USES
 To collect secretions
 To determine location of pathologic
process and collect specimen for biopsy
THERAPEUTIC USES
 To remove aspirated foreign objects
 To excise small lesions
NURSING INTERVENTIONS BEFORE BRONCHOSCOPY
 Informed consent
 Atropine and Valium pre- procedure as
prescribed; topical anesthesia sprayed
into the throat followed by local
anesthesia injected into larynx
 NPO for 6 to 8 hours
 Remove dentures, prostheses, contact
lenses
NURSING INTERVENTIONS AFTER BRONCHOSCOPY
 Side- lying position
 Check for return of cough and gag
reflex before giving fluids
 Watch out for cyanosis, hypotension,
tachycardia, arrythmias, hemoptysis,
dyspnea
LUNG SCAN
 Following injection of a radioisotope,
scans are taken with a scintillation
camera.
 Measures blood perfusion through the
lungs
 Confirms pulmonary embolism or other
blood- flow anomalies
 Instruct the client to remain still during
the procedure
SPUTUM COLLECTION
 To assess for gross appearance of the
sputum
 Sputum C and S (Culture and
Sensitivity Test)- this is done to detect
the actual microorganisms causing
respiratory infection
 AFB Staining (Acid Fast Bacillus Stain)-
to detect PTB
PROPER COLLECTION OF SPUTUM
 Early morning sputum specimen is to be
collected
 Advise the client to rinse mouth with plain
water
 Use sterile container
 Sputum specimen for C and S is collected
before the first dose on antimicrobial
 For AFB staining, collect sputum specimen
for 3 consecutive mornings
BIOPSY OF LUNG
 Transbronchoscopic biopsy- done
during bronchoscopy
 Percutaneous Needle Biopsy- done
with the use of aspiration needle
 Open Lung Biopsy- done during surgery
 Lymph Node Biopsy- scalene or
cervicomediastinal- to assess
metastasis of lung cancer
ARTERIAL BLOOD GAS STUDIES
  To assess ventilation and acid- base
balance
 Radial artery is the common site for
withdrawal of blood specimen
 Allen’s test is done to assess for
adequacy of collateral circulation of the
hands
 Use 10 ml pre- heparinized syringe to
draw blood specimen.
 Place the specimen in a container with
ice

PULSE OXIMETRY

 To determine oxygen saturation in the

blood
 95% to 100%- normal range
 The pulse oximeter sensor is placed in
the index finger or ear lobe
 The sensor should be covered with
opaque material. The reading can be
affected by sunlight

THORACENTESIS

 Aspiration of fluid or air from the

pleural space

NURSING INTERVENTIONS BEFORE THORACENTESIS

 Secure written consent

 take initial vital signs
 Position: upright, leaning on overbed
table
 Instruct the client to remain still, avoid
coughing during insertion of needed
 Turn the client on unaffected side
 Bed rest
 Check for expectoration of blood
 Monitor vital signs