Group 4 Record Management: Patient's Chart & Kardex PDF
Document Details
Guimawa, Xynneth
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Summary
This document provides a detailed overview of record management procedures, including patient charts, kardex systems, and disaster recovery plans for healthcare facilities. It emphasizes the importance of secure and accurate record-keeping, and details relevant information on various aspects, including patient data management, information security, and disaster response.
Full Transcript
**NCM 119:** **NURSING LEADERSHIP AND MANAGEMENT** **WHAT IS A KARDEX?** - - - **MAINTENANCE OF NURSING KARDEX** - - - - - - **Method of filling Kardex** **I. Identification Data:** - - - - - **II. Medication:** a. b. c. d. e. **III. Treatments:** a...
**NCM 119:** **NURSING LEADERSHIP AND MANAGEMENT** **WHAT IS A KARDEX?** - - - **MAINTENANCE OF NURSING KARDEX** - - - - - - **Method of filling Kardex** **I. Identification Data:** - - - - - **II. Medication:** a. b. c. d. e. **III. Treatments:** a. **IV. Nursing Care Plan** a. - - - - - - - - - - - - - - - - - - - - - - - - - - - **Kardex Management** - - - **PATIENT'S CHART/ MEDICAL RECORDS** It promotes clear communication and facilitates effective decision-making. A well-organised medical chart typically follows a standardised format to ensure consistency and accuracy. **Parts of a Patient's Chart:** 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. **Importance of a Patient's Chart:** 1. 2. 3. 4. 5. 6. **MANAGEMENT OF RELEASING PATIENT INFORMATION/RECORD** *All medical records information is deemed to be strictly confidential and cannot be disclosed to any unauthorised personnel under any circumstances without proper authorization. Certain exceptions which require hospitals to release the medical information of a patient are as follows:* 1. 2. 3. 4. 5. 6. **MANAGEMENT OF RECONSTRUCTING MEDICAL RECORDS:** A disaster recovery plan is crucial for every healthcare facility in the event of a failure of the medical records department to preserve the records of the patients. Simple steps that can be taken to safeguard the medical records in an unforeseen circumstance are 4's: 1. 2. 3. 4. **DESTRUCTION OF MEDICAL RECORDS** 1. 2. *A simple medical record destruction form would contain the following:* 1. 2. 3. 4. 5. 6. **REMEMBER: As the saying goes, " IF IT WAS NOT CHARTED, IT WAS NOT OBSERVED OR DONE"** ***[References: ]*** - - - - - - Members: Ore, Zennia Ericel Montero, Khate Emerlyn Cruz, Shekinah Arrielle Nacatab, Alvin Greg Balbin, Rhona Borja, Verlene Jessamine Mano, Maricar Umayat, Althea Abidal, Ira Comaad, Carreonellae Crosby, Arlyn Joyce Guimawa, Xynneth
