CLIENT RECORDS

• Client record ( chart, clinical

record) – is a formal, legal document
that provides evidence of a client’s
care.
1. Communication
 Serves as a vehicle by which different health
professionals who interact with a client
communicate with each other
 This prevents fragmentation, repetition, and
delays in client care

Purposes of Client
Records
2. Planning client care
 Nurses use baseline and ongoing data to
evaluate the effectiveness of a nursing care
plan
 Each professionals uses data from the client’s
record to plan care for the client
3. Auditing health agencies
 An audit is a review of client records for
quality assurance purposes
 Accrediting agencies (such as JCAHO) may
review client records to determine if a
particular health agency is meeting its stated
standards
4. Research
 The information contained in a record
can be a valuable source of data for
research
 The treatment plans for a number of
clients with same health problems can
yield information helpful in treating
other clients
5. Education
 Students in health disciplines often use
client records as educational tools.
 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
 Documentation also helps a facility receive
reimbursement from the government
 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.
 Accurate, thorough recording by nurses will
facilitate reimbursement from these agencies
7. Legal documentation
 The client’s record is a legal document and
is usually admissible in court as evidence
 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
 Information from records may assist
health care planners to identify agency
needs, such as overutilized or
underutilized hospital services
 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
1. Admission (face) sheet
 Legal name, birthdate, age, gender
 Social security number
 Address
 Marital status; closest relatives or
person to notify in case of emergency
 Date, time, and admitting diagnosis
 Food or drug allergies
 Name of admitting (attending) physician
 Insurance information (if any)
 Any assigned diagnosis-related group (DRG)

Components of a Patient’s Chart

2. Physician’s Order Sheet
 Record of physician’s orders for treatment and
medications, with date, time and physician’s signature
3. Nurse’s Admission Assessment
 Summary of nursing history and physical assessment
4. Graphic Sheet and Flow Sheet
 Record of repeated observations and measurements
such as vital signs, daily weights, and intake and
output

Components of a Patient’s Chart

5. Medical History and Examination
 Results of initial examination performed by physician,
including findings, family history, confirmed
diagnosis, and medical plan of care
6. Nurses’ Notes
 Narrative record of nursing process: assessment,
nursing diagnosis, planning, implementation, and
evaluation of care
 FDAR, SOAPIE

Components of a Patient’s Chart

7. Medication Records
 Accurate documentation of all medications
administered to client: date, time, dose, route, and
nurse’s signature
8. Physician’s Progress Notes
 Ongoing record of client’s progress and response to
medical therapy and review of the disease process

Components of a Patient’s Chart

9. Health Care discipline’s records
 Entries made into record by all health-related
disciplines: radiology, social work, and laboratories
10. Discharge summary
 Summary of client’s condition, progress, prognosis,
rehabilitation, and teaching needs at time of dismissal
from hospital or health care agency

Components of a Patient’s Chart