Question

Let's discuss some of the various forms/documents in the health record - whether it is in paper or electronic form. Select a form used to collect information in an acute hospital setting and tell us about that form. Why is that form important ?

Answer 1

Forms or documents used in the health sector are the vital part of health services as they are the chief evidences of the care provided to the patient . Various forms or documents used in the health record are :-

- Face sheet in which patient identical data is present for example name, age ,sex , diagnosis ,name of the ward etc

- Vital chart in which hourly assessed vital status is documented.

- Nurses chart in which nurses document the care ,procedure provided, medication administered, nursing care plan

- Treatment chart in which all medication given is charted

- discharge sheet used in case of discharge

- transfer form used when the patient is transfered from one ward to another .

- death form used when patient dies

- LAMA form when patient leaves against medical advice

All the above mentioned forms are important and has to be filled at the same time of the process.

I have selected the nurses chart - it's very important for the nurses to document the procedures ,any fluctuations in the vitals of the patient , care provided , medicines administered etc at the same time because when any serious event occurs with the patient it's the nurses chart seen first because nurses are the one in the health professional who spends more time with the patient and hence, her records are used for the evidence and also if there is any mistakes . It's important from the nurses part to mention the or document the duties or care provided to be at safest part .

Nurse should document neat and clean notes with out any cuttings , overwritings. Should put the signature ,time and date after documentation and document only after the procedure is done .