Where The *&^! do I Find My Patients Information?

PERSIAN GULF (April 9, 2007) – Hospital ...

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According to information obtained through a book called ConceptMapping: A Critical-Thinking Approach to Care Planning by Pamela Schuster, 99% of assessment data comes from the documentation you find in the medical chart.  This can be hellaciously time-consuming and confusing to dig through.  So here are some pointers from that , that should help you find everything.

1)      The  Patient’s Chart

a)      Face Sheet

i)        Patients age (important for how age plays apart in their illness.)

ii)       Gender

iii)     Past medical history

iv)     Marital status

v)      Occupation

vi)     Admission date

vii)   Reason for admission

(1)    Admitting diagnosis

(2)    Possible planned surgeries

 

b)      Doctor’s Order Sheets/Physicians Orders

i)        any code status

ii)       diet

iii)     activity allowed

iv)     orders for lab and diagnostic procedures

v)      medication orders

vi)     IV orders

vii)   Other treatments (like o2 , caths, NG tubes, dressing changes)

viii)  Supportive services (physical therapy, occupational therapy, speech therapy, respiratory therapy, social workers, case manager)

ix)     Consultations by other MDs usually specialists

c)       Physician’s Progress Notes

i)        the patient’s progress and response to medical treatment

ii)       changes in the patient’s condition

iii)     medical and surgical procedures that have been performed and  findings

iv)     results of tests and procedures

d)      Doctor’s History and Physical Exam

e)      Physician Consultations

i)        The patient’s H&P by the admitting physician that includes a review of systems and past medical, family and social history

ii)       Any consultation reports that may also have some review of systems and past medical history

iii)     The consultation section may contain consults by other ancillary services that don’t have their own section in the chart.

f)       Surgical Consents

i)        The name of the exact procedure or procedures the patient has had or is to have ( a surgical consent must have the complete name of the procedure written out (NO ABBREVIATIONS) and the doctors full and complete name and title.

g)      Operative Report

h)      Pathology Report

i)        Date and name of surgical procedures done by physicians

ii)       Medical diagnoses

iii)     Findings

iv)     Full description of the procedure and any materials/prostheses placed in the patient’s body

v)      Report on any tissue biopsied or removed during a surgical procedure

i)        Laboratory and Diagnostic Procedures

i)        Date and time of collection and analyhsis/examination of blood, urine, stool and other body substances

ii)       Blood bank records and blood transfusion consent forms

iii)     Xray reports

iv)     EKG

v)      EEG

j)        Nursing Admission Assessment

i)        Past medical diagnoses

ii)       Past illnesses, injuries and surgeries

iii)     Advanced directives, living wills, healthcare POA

iv)     Height and weight

v)      Allergies

vi)     Medications taken at home

vii)   Home caregiver

viii)  Nursing review of systems

ix)     Nursing assessment of the patient’s ability to perform ADL’s

k)      Nurses notes/Flow Sheets/Graphic Sheets

i)        Graphic information (vital signs,)

ii)       I&O information (will usually include any IVF’s and catheters)

iii)     BM monitoring

iv)     Activity performed

 

 

Other Resources On the Nursing Unit

 

1)      Medication Cart

a)      MAR

b)      Iv therapy records

  1. 1.       Allergies 
  2. 2.       Drugs/dosages/routes/times
  3. 3.       IV solutions to be infused and rates.

2)      The Nurses Station

a)      Kardex

  1. 1.       Allergies (food and drug)
  2. 2.       Age, gender, admission date
  3. 3.       Diet
  4. 4.       Activity allow2ed
  5. 5.       IV orders
  6. 6.       Surgical procedures
  7. 7.       DNR orders
  8. 8.       Diagnostic tests to be done
  9. 9.       Ordered treatments
  10. 10.   Support services
  11. 11.   Consultations

 

 

Blank copies of forms you are going to have to document on the next day to become familiar with what information goes on them and where .  These forms can include: 

                Assessment forms

                Fall risk assessment forms

                Standardized pre-written care plans/clinical pathways

                Printed copies of standing orders

                Educational materials that might apply to your patient

             

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