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Chapter: 11th Nursing : Chapter 13 : Documentation

Nursing: Records

Records are one of the essential components of documentation.


Records are one of the essential components of documentation.


Types of Records

1.        Patients Clinical Records

It is the record of events in the patient illness, progress in his or her recovery and the type of care given by the hospi-tal personnel.

2.        Individual staff records.

A separate set of record is needed for staff, giving details of their absences, their carrier development activities and a personnel note.

3.        Ward Records

These records are maintained in the each ward, such as

·           Census records.

·           Change in medical staff and non nursing personnel for the ward. (Duty roaster)

·           Inventory and stock records

·           Staffs Leave records

·           Admission records

·           Transfer records

·           Discharge records

·           Medicine records etc.

4.        Administrative records

These records are maintained purely for administrative purpose of the hospital or unit

·           Legal documents: for the patients with poisoning, assault, rape, burns etc.

·           Research or statistics data records

·           Audit and nursing audit records

·           Quality of care records

·           Personnel performance. records

·           Other administrative records


Records Maintained by the Nurses

Vitals sign chart on this the temperature, pulse and respiration are written in a graphic form so that a slight deviation from the normal can be noted at a glance

INTAKE AND OUTPUT CHART; Intake and out put chart to be maintained for the critically ill client those who received intravenous fluids, postoperative clients, clients with oedema, and client suffering with vomiting and diarrhoea,


Nurses notes are a record of treatments and nursing measures carried out by the nurse which reflects the observation of the client.


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