Learning objectives:- 1. Introduction. 2. Define health record. 3. Explain types of health record. 4. Mention purposes of health record. 5. List general guideline for recording.

Introduction Health personal communication Record Discussion Report

1- Definition of health record.  An electronic health record (EHR) (also electronic patient record (EPR) or computerized patient record) is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations

Types of health record. Health records take many forms and can be on paper or electronic. * Different types of health record include:-

1- Hospital admission records: This including in.  Patient’s demographics data ( Name, age and sex).  Address.  Occupation.  Marital status.  Religion.

 Patient’s problem ( the reason for admitted to hospital).  past medical history (If patient have any chronic health conditions, such as diabetes or asthma,…).  Physical assessment for body system.

 If patient have any allergies from currently taking medication or previously had any adverse reactions to certain medications,  The treatment that patient will receive.  Height and weight.

2- Hospital discharge records : which will include the results of treatment and whether any follow-up appointments or care are required.

 Flow Sheet:- it enables nurses to record nursing data quickly, concisely and provides an easy-to-read record of the client’s condition over time. 3- Graphic Record : this record typically indicates body temperature, pulse, respiratory rate, blood pressure. 4- Fluid Balance Record : all routes of fluid intake and all routes of fluid loss or output are measured and recorded on this form.

5- Medication Administration Record: medication flow sheets usually include designated areas for the date of the medication order, medication name and dose, the frequency of administration and route and the nurse’s signature. 6- Skin Assessment Record: a skin or wound assessment is often recorded on a flow sheet. These records may include categories related to stage of skin injury, drainage, color, odor, and treatment.

7- Progress Notes : it made by nurses provide information about the progress a client is making achieving desired outcomes. - Progress notes include information about client problems and nursing interventions. 8- Laboratory, x ray and radiology report.

Ensuring Confidentiality of computer record:-  Personal password.  Never leave the computer terminal unintended.  Don’t leave client information displayed on the monitor.

healthcare records is to record important clinical information, which may need to be accessed by the healthcare professionals involved in patient care. 1- Communication: Patients record prevent. Fragmentation. Repetition. Delay in patient care. Purposes of health records

Purposes of health records Cont. 2- Planning client care. 3- Auditing health agencies. An audit is a review of client records for quality assurance purposes. 4- Research.

Purposes of health records Cont. 5- Education. 6- Legal documentation. 7- Health care analysis. 8- Reimbursement. Documentation helps a facility receive reimbursement from government

General guideline for recording: 1- Date and time. 2- Legibility. 3- Permanence. 4- Accepted terminology. 5- Correct spelling. 6- Signature. 8- Accuracy. 9- Sequence. 10- Appropriateness. 11- Conciseness. 12- Preferable abbreviations. 13- Completeness.