Patient Chart Records and Discharge Summary

Patient Chart Records

• Patients hospitalized for medical treatment are admitted to a nursing unit.
• Medication Profile: quick reference of drugs the patient is taking (current and hold).
• Orders/Directives: recorded on Physician's Order Sheet (POS).
• Medication Administration Record (MAR): personalized document for each patient, used to record dose, time, route, and record of medications given.
• Vital Sign Record: graphic representation of temperature, pulse, respirations/respiration rate, and blood pressure.
• Patient Label/Form/Form Imprint: must be used when adding a physician's order form to a patient's chart.
• Allergies: are noted for each patient.
• Kardex: kept in a Kardex holder at the nursing unit.

Discharge Summary

• Completed by the physician when a patient is discharged.
• Brief summary of the patient's care and history.
• Kardex information may include Activity, In's, Care Plans, Lab Tests, Diagnostic Tests, Treatments, Diet, and Degree of Intervention (most).
• Admission Record: the first form completed.
• Allergy / Adverse Reaction Record: completed by nursing staff.
• Discharge Summary: completed by physician.
• Communication Sheet: used for communicating urgent information to the doctor.
• Additional information on Admission Record: includes Name, Physician(s), Next of Kin (NOK), Admission Date, Address, and PHN.
• Discharge Instructions: completed by nursing staff.
• Signature Identification Record: includes initials, printed name and signature, and designation for staff.

Medication Administration Record (MAR)

• MAR: Used to record medications – dose, time, and route.

Name Alert

• Method for alerting staff to patients with the same last name in the same nursing unit.

Inpatient Treatment

• Patient admitted to a health care facility for at least one night.

Nursing Admission History

• Form completed by the nurse to give overall past and present history of the patient upon admission.

Kardex Update Method

• Pencils are used to update physician orders on the Kardex; it's easier to update and make changes with pen.

Admission Chart Pack Forms

• Forms assembled in an admission chart pack by the Unit Clerk include: Progress Notes, Signature Record, Nursing Admission History, Nursing Flowsheet, MAR, Medication Profile, Orders Directives, Kardex and Vital Sign Record.

Abbreviations

• UC: Unit Clerk
• HX: History
• NAS: No Added Salt
• T: Temperature