Records are one of the essential
components of documentation.
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
Individual staff records.
A separate set of record is needed for staff, giving
details of their absences, their carrier development activities and a personnel
These records are maintained in the each ward, such as
in medical staff and non nursing personnel for the ward. (Duty roaster)
and stock records
These records are maintained purely for
administrative purpose of the hospital or unit
documents: for the patients with poisoning, assault, rape, burns etc.
or statistics data records
and nursing audit records
of care records
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.