Medical Documentation Types and Patient Data Recording Methods

Medical Record

Legal Document describing the care that is delivered to a patient

EMR

Electronic version of medical records

Objective Data

Precise measurement, correct spelling, proper use of abbreviations

Legal Document

A nurse's signature on an entry in a record designates accountability for the contents of that entry

Financial record

Basis for reimbursement

Types of documentation

Flow sheets and graphic records, Admission Nursing History Forms, Patient Care Summary or Kardex, Standardized Care Plans, Discharge Summary Forms, Narrative documentation

Narrative documentation

Traditional method using a story-like format to document information specific to the patient

Disadvantages of Narrative documentation

Repetitious, time consuming, hard to sort through to find what data you are looking for

Vital Signs

T: 98.7 ° F; P: 84 regular 2+ bilaterally, R: 16, B/P: 120/72

Pain Assessment

Reports stabbing pain in left anterior thigh, began after running one hour prior to assessment, localized, rates pain 6/10

Pain Assessment details

Walking makes pain worse, ice pack makes pain better, states pain is interfering with concentration during class