Module 2

Documentation – Medical Records,

Filling in Medical / Nursing Documentation

Author:
Carol Finlay
Fastrack into IT (FIT Ltd)
www.fit.ie
30  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on

INTRODUCTION
This module will introduce healthcare professionals and students to various medical
documentation types. Medical documentation is an integral part of work for healthcare
professionals. Comple ng pa ents’ records and taking vital signs such as temperature, pulse
etc. are frequent duty for nurses. The quality of notes, charts and forms is crucial for pa ents’
recovery process and overall wellbeing in the future.
This unit covers different medical forms, gives overview of common abbreviations and
acronyms currently in use by medical professionals, provides students with some medical
terminology and descrip ve vocabulary to make clear, coherent and accurate notes in order
to avoid poten al complica ons or even fatali es. Learners will be given plenty of prac ce
of this type of ac vity through role-play, listening, speaking exercises as well as enhance and
get familiarised with the medical vocabulary. Thus upon the comple on of the module the
students will possess the necessary knowledge of documenta on prac ses and will be able to
communicate efficiently at B1/B2 levels in a professional manner using standardised medical
language.

OBJECTIVES
The outcomes of this module are the following:
• knowledge of the different types of medical forms;
• knowledge of best prac se in comple ng forms and pa ents’ records;
• knowledge of basic medical terminology, standardised abbrevia ons and acronyms used
by medical professionals;
• ability to describe symptoms to make accurate, complete and objec ve notes;
• ability to communicate effec vely with healthcare colleagues and pa ents.

LISTENING 1
Listen to key words presented below. Pay special a en on to their correct pronuncia on.
Then listen for the second me and repeat.

documen ng recording self-disclosure repor ng medical

terminology
/ˈdɒkjʊmentɪŋ/ /rɪˈkɔːdɪŋ/ /self-dɪsˈkləʊʒə/ /rɪˈpɔːtɪŋ/ /ˈmedɪkəl
tɜː.mɪˈnɒlədʒi/
pa ent record analysing assimila on communica on chart notes
(barrier)
/peɪʃənt ˈrekɔːd/ /ˈænəlaɪzɪŋ/ /əˌsɪmɪˈleɪʃən/ /kəˌmjuːnɪˈkeɪʃən /tʃɑːt nəʊts/
bæriə(r)/

LISTENING 2
“Filling in a Nursing Admission Assessment form”. Listen to the conversa on between a nurse
and a pa ent and fill in the form below. (the conversaƟon will not give you all informaƟon
requested on the form)
  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on 31

NURSING ADMISSION ASSESSMENT

Biographical Data

Name: Age: to be calculated Address:

Date of Birth:

Consultant: no info in the script

Preferred Name: Na onality: Telephone Numbers:

Home:

Mobile:
Name of Next of Kin: Can the pa ent communicate in English?

Yes   No 

If no what is their first language?

1. Name of first contact TELEPHONE:

person:
Home: no info

Rela onship: Work: no info

Mobile:
2. Name of second contact TELEPHONE:
person:
Home: no info

Rela onship Work: no info

Mobile:
G. P. Name Telephone: ADDRESS

SPEAKING 1
CONSENT FORM. Read the following role play scenario and then complete the exercise
described below.

Exercise: Break up into groups of three or more. Appoint one person as the medical professional
and one as the pa ent (older person) and the others to act as observer(s). Pick a medical
procedure that you or your group are knowledgable of e.g. appendectomy.

Sugges on for self-learners: Skype or call a person and role play the consent form with you
as the medical professional the other person as the older person.
32  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on

Role play through the consent form (below) with the (older person) pa ent. The healthcare
professional will complete the Consent Form (below). This can be done in a classroom se ng
or with just three people. One person playing the health professional, one playing the older
person and the other be observers who give feedback on the following:
1. Iden fy two things that the healthcare professional did well e.g. bedside manner, clear
explaina on of procedure.
2. Name one thing that the healthcare professional could improve on e.g. speaking more
loudly or clearly.

SPEAKING TIPS
When speaking to older people it is important to be aware of their health problems that could
make it difficult for them to speak, hear or understand. If you can find a quiet loca on, speak
clearly and ensure that ques ons and sentences short clear and precise.
Be friendly, take your me speaking, be pa ent and smile.
Tips for an Older Person: If ques ons are not clear and no eye contact is made, please ask for
the Healthcare Professional to repeat or rephrase a ques on.

CONSENT FORM
Pa ent Agreement to Inves ga on or Treatment

DETAILS OF PROCEDURE OR COURSE OF TREATMENT PROPOSED

Name of proposed procedure or course of treatment (include brief explana on if medical term
not clear)

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Site and Side of opera on or procedure

________________________________________________________________________________

________________________________________________________________________________

Has site been marked?    Yes    No    Not Applicable

Statement of Healthcare Professional

(to be filled in by Healthcare Professional with appropriate knowledge of the proposed procedure, as
specified in consent form)
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I have explained the procedure to the pa ent. In par cular I have explained:

Serious or frequently occurring risks such as:

________________________________________________________________________________

________________________________________________________________________________

Any extra procedures which may become necessary during the procedure
 Blood transfusion  other procedure (please specify)

________________________________________________________________________________
I understand that any procedure in addi on to those described on this form will be only carried out if
it is necessary to save my life or prevent serious harm to my health.
I have been told about addi onal procedures which may become necessary during my treatment.
I have listed below any procedures which I do not wish to be carried out without further discussion.

STATEMENT OF PATIENT
I agree to the procedure or course of treatment described on this form.
I understand that you cannot give me a guarantee that a par cular person will perform the procedure.
The person will, however, have the appropriate experience.

Pa ent’s signature …………………………………………………… Date ……………………………

Name (PRINT) ......................................................................................................................................

Signed Doctor .......................................................................................................................................

Doctor’s Name (Please Print) ..............................................................................................................
Job Title ...............................................................................................................................................

READING 1
RULES FOR ABBREVIATIONS.1 Read the text and answer the ques ons presented below.
Abbrevia ons can be very benefical when filling in forms and wri ng le ers, but you need
to be very careful and only use words that have been approved by the organisa on you are
working for.
All abbreviations should be written in Block Capitals (e.g. MI – Myocardial Infarction).
Contrac ons can be wri ten as a mixture of higher and lower case but should be avoided if
at all possible. In the event of abbrevia ons being u lised the following are situa ons where
you shoud NEVER use them.
When wri ng down a decision regarding resuscita on of a pa ent it should always be wri en
out in full and signed. A decision of such gravity should never be abbreviated. Under no
circumstances should drug names be abbreviated, as abbrevia ng medica on may cause the
wrong medica on to be given to the pa ent.
1 
Health Service Execu ve: Code of Prac ce for Healthcare Records Management: Abbrevia ons: 2010, p. 4–6; h p://goo.
gl/e5EVnW.[29.02.2016]
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When wri ng Right and Le it is important that it is wri en out in full. All services and service
users/pa ent’s must be given their full name. Death cer ficates, consent forms, external
referral le er, medica on sheets and incident report forms should never include abbrevia ons.

Q1. Choose at least three types of documenta on where you should never use abbrevia ons.
Q2. Why should drug names never be abbreviated?

LANGUAGE FOCUS 1
TYPES OF FORMS. Match the following types of forms with the informa on they show and
their func on: Check pronuncia on of the unknown words.

Medical History Form

Discharge Summary
Medicine / Drug Chart
Laboratory Results
Radiological Reports
Pa ent Observa on Chart
Consent Form
Falls Risk Assessment Form
Fluid Balance Chart
Nursing Assessment Form

1 Gathers informa on on a pa ent through interview and observa on

on their physiological, psychological, sociological, and spiritual status
to assess their needs.
2 A report from the use of an ultrasound, computed tomography (CT)
or nuclear medicine, positron emission tomography (PET) or magne c
resonance imaging (MRI) which is used to diagnose or treat diseases.
3 A record used to monitor input and output of fluids.
4 This chart is used to record vital signs and other clinical informa on
in hospitals, and has a key role in iden fica ng of pa ents who are
deteriora ng.
5 A record of drugs prescribed or dispensed to a pa ent.
6 To iden fy high falls risk for pa ents.
7 A record of facts rela ng to past and present health.
8 The results of laboratory examinations, usually with analyses and
findings.
9 This is a form signed by a patient prior to a medical procedure to
confirm that he or she agrees to the procedure and is aware of any
risks that might be involved.
10 This form includes a diagnosis, procedures and follow-up arrangements,
to be provided for the general prac oner (GP) on the discharge of
a pa ent from hospital.
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SPEAKING 2
Asking the right ques ons to get a detailed Medical History.
Break into groups of two. One person is the healthcare professional whose role is to document
the medical history of the other person who role plays the pa ent. Then swap around. Discuss
and compare informa on you got from each other and what other ques ons you used to get
the relevant informa on.

Sugges on for self-learners: Skype or call a person where you are the healthcare professional
documen ng his/her medical history and the other person the pa ent. You also may use
the ques ons from language ps below to make a monologue with your personal answers
and/or take not of your medical history.

LANGUAGE TIPS 1
Ques ons to help you gather the relevant informa on:
Have you ever received medical care? If so, what problems/issues appeared?
Have you ever undergone any procedures, X-Rays, CAT scans, MRIs or other special tes ng?
Have you ever been hospitalised? If so, for what?
Have you ever been operated on, even as a child?
What year did this occur?
Were there any complica ons?

LISTENING 3
“Best pracƟce for healthcare documentaƟon – a lecture.”2 Once you have listened to the
lecture answer the ques ons below:
The hospital has recently employed a number of healthcare workers. As part of their introduc on
they are asked to attend the following lecture to ensure that procedures in recording
documenta on are clear and of a high standard.
1. What are the general requirements for all entries in the healthcare record?
2. What two ac ons should you do to ensure that you take care of the correct pa ent?
3. If wri ng in informa on that is retrospec ve what data do you need to include?
4. Name the two types of documenta on where abbrevia ons should not be used.

LANGUAGE TIPS 2
Defini ons from LISTENING 3.
Con nuity of care: is concerned with quality of care over me;
Iden fica on label: printed with barcodes and pa ent informa on;
Iden ty band: is used to iden fy hospital pa ents;
Legible: wri ng that is clear enough to read;
Dele ons: the removal of wri en or printed ma er;
Altera ons: changes in wri en or printed ma er;

2 
Health Service Execu ve: Standards and Recommended Prac ces for Healthcare Records Management, 2011, p. 73–77;
h p://goo.gl/UlR7UH. [29.02.2016]
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Counter signature: an addi onal signature on a document that has already been signed;
Retrospec ve entry: entry to documenta on made for ac on / care that occured in the past;
Amendment: a minor change or addi on to a text;
Iden fica on number: staff number (allocated by employer).

LANGUAGE FOCUS 2
HOSPITAL DEPARTMENTS. Iden fy which department from the list below the person is
a ending based on the informa on given. Check pronuncia on of the unknown words.
A er comple ng the table, break up into pairs and check answers, bearing in mind correct
pronuncia on.

Suggestion for self-learners: Fill in the table. Check your answers with the key and
pronunica on.

Accident & Emergency (A&E) Otolaryngology Oncology

Cardiology Radiology Dermatology

Speech & Language Therapy

Ophthalmology Occupa onal Therapy Rheumatology

1 The person has been involved in a car accident.

2 The person has recently suffered a heart a ack.
3 The person has severe dermatosis.
4 A person has recently had a brain injury which has le the person with
mobility issues.
5 The person has been diagnosed with breast cancer.
6 The person has fallen off a wall, they landed heavily on their right arm
which is very painful.
7 The person is having difficultly speaking a er recently suffering a stroke.
8 The person has arthri s in her hands.
9 The person is suffering from blurred vision.
10 The person requires tonsillectomy.
  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on 37

VIDEO CLIP 1
“Falls Risk Assessment.” Watch the video clip where the nurse is interviewing Mr Doyle who
has recently suffered a stroke. Complete the FALLS RISK ASSESSMENT FORM (below). Would
you implement the Risk of Falling Care Plan?

FALLS RISK ASSESSMENT FORM

Please complete Falls Risk Assessment on all pa ents over 65 years and on pa ents in specific risk
groups (e.g. pa ents with Stroke, Epilepsy, Head Injury).
Use this form to ideni y pa ents risk of falling.

FALLS RISK ASSESSMENT TOOL

Answer the following ques ons: (please circle as appropriate)

1. Has the individual had a fall in the last six months? Yes = 1 No = 0

2. Is the individual agitated? Yes = 1 No = 0

3. Is the individual visually impaired that would effect everyday tasks? Yes = 1 No = 0

4. Is the individual in need of frequent toile ng? Yes = 1 No = 0

5. Is Transfer + Mobility Score 3 or 4? (see below) Yes = 1 No = 0

Risk Factor Assessment Score:

Transfer Score Mobility Score
0 = unable to transfer 0 = immobile
1 = major help need (1–2 people or hoist) 1 = independent with aid of wheelchair
2 = minor help needed (oral prompt to transfer) (or with 2 people)
3 = independent with transfer 2 = walks with help of one person
(or with aid / aid and 1 person)
3 = independent
Transfer Score: Mobility Score: Add Transfer and Mobility Score:

Risk Factor assessment Score (add answers 1–5) =

N.B. SCORE OF ‘2’ OR MORE INDICATES A HIGH RISK OF FALLING

IF PATIENT AT RISK OF FALLING, PLEASE IMPLEMENT RISK OF FALLING CARE PLAN

Nurse Signature: ___________________________________ Date __ /__ /____

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LANGUAGE FOCUS 3
COMMON MEDICAL CONDITIONS. Match the most common medical condi ons with their
defini ons. Check pronuncia on of the unknown words.

1 Chronic Obstruc ve A a serious medical emergency in which the supply of blood to the
Pulmonary Disease heart is suddenly blocked, usually by a blood clot.
(COPD)
2 Diabetes B a group of condi ons where the body’s cells begin to grow and
reproduce in an uncontrollable way.
3 A heart a ack C virus infects your lungs and upper airways, causing a sudden high
temperature and general aches and pains.
4 Asthma D is a long-term condi on caused by too much glucose, a type of
sugar, in the blood.
5 Chickenpox E a collec on of lung diseases including chronic bronchi s,
emphysema and chronic obstruc ve airways disease
6 Cancer F a highly infec ous viral illness. It causes a range of symptoms
including fever, coughing and dis nc ve red-brown spots on the
skin.
7 Flu G a condi on that affects the airways.
8 Measles H a rash of red, itchy spots that turn into fluid-filled blisters.

SPEAKING 3
Break up into groups of two or three and select two forms from
the list below, discuss and answer the ques ons below:

Sugges on for self-learners: Select two forms and answer the ques-
ons below.
What is the form used for?
What specific informa on would a healthcare professional require
for the form?

Nursing Assessment Form Medical History Form Pa ent Observa on Chart

Laboratory Results Radiological Reports Consent Form
Fluid Balance Chart Medicine / Drug Chart Falls Risk Assessment Form

WRITING 1
Select one type of a form from the list below. Inden fy the specific informa on required in
the selected form and ensure so that the form fufills it’s role. Check your findings with the
key.

Nursing Assessment Form Medical History Form Pa ent Observa on Chart

Laboratory Results Radiological Reports Consent Form
Fluid Balance Chart Medicine / Drug Chart Falls Risk Assessment Form
  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on 39

TIP
Any Medical Form should include Chart Number, Pa ent’s First Name and Surname and his
Date of Birth.

SPEAKING 4
Break up into groups of two or three and discuss the importance and role of good quality
Referral Le ers. As part of the discussion, iden fy and record the key pieces of informa on
that would be required in a Le er.

Sugges on for self-learners: Skype or call a person and discuss ….Alterna vely, prepare a short
statement about Referral Le ers. If possible, include your professional experience. Imagine
that you have to explain it to a virtual colleague and make a monologue.

Referral of pa ents to secondary care specialists or other health professionals is part of

everyday practice for general practitioners. Investigation of symptoms, access to special
diagnos cs, confirma on of diagnosis, assistance in management of acute or chronic disease
or specialist management of a complex medical problem are all reasons for GP referral.3

WRITING 2
Using a case from your own experience, write a detailed Referral Le er. It should include all
the key informa on that you have iden fied in the SPEAKING 4 exercise.

LANGUAGE TIPS 3
Mr Doyle has been The results for tests are ……… The treatment Mr Doyle has
experiencing ……… undergone is ………
In my opionion Mr Doyle is He is allergic to ……… Mr Doyle has the following
suffering from ……… ailments / illnesses
Mr Doyle is currently on the Mr Doyle lives ……… I have referred Mr Doyle to you
following medica on ……… because ……….

SPEAKING 5
Break up into groups of two or three. Discuss the role and importance of informa on leaflets
on illnesses and condi ons, how they can help to inform both pa ent and family members.

Sugges on for self-learners: Skype and call a person and discuss or prepare a short statement
about informa on leaflets. If possible, include your professional experience. Imagine that you
have to explain it to a virtual colleague or pa ent and develop a monologue.

TIP
Informa on Leaflets are available on a majority of common illnesses including Cancer, Diabe es,
Asthma, COPD etc.

3 
John MacCarty: The GP referral le er- me for something new: 2010, h ps://goo.gl/CYEUIA [25.04.2016]
40  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on

LANGUAGE CORNER
The following expressions have been selected to act as the building blocks for successful
communica on regarding the subject addressed in this module. They will support you in
crea ng adequate subject related sentences and expressions to meet the communica ve
requirements in any professional situa ons you may encounter.

assessing ability to walk iden fying a tude toward care

consul ng care provider demen a
drug dependence pain control
assessing for signs of discomfort acute confusion
test result non adherence to diagnos c tes ng regime
protocol appropriate self disclosure
monitoring blood pressure informing about hospitalisa on
examining radiology department
measuring body temperature occupa onal therapist
improved agita on verifying consent before opera on
self care deficit oxygen therapy
difficulty using verbal communica on severe nausea
evalua ng treatment regime symptom control
suppor ng family trea ng injury
verifying death knowledge of response to procedure

SUMMARY
Having completed this module, you have:
• developed the listening, writing and speaking skills to communicate effectively with
healthcare professionals and pa ents;
• gained an understanding of the different types of medical forms;
• implemented and understood the best prac se in comple ng forms and pa ents’ records;
• developed your knowledge of basic medical terminology, standardised abbrevia ons and
acronyms used by medical professionals;
• implemented your knowledge to describe symptoms to make accurate, complete and
objec ve notes.

REFERENCES
1. ICNP catalogue: ICNP® English 6 November 2013; h p://goo.gl/Y3mQtS. [21.02.2016]
2. Health Service Execu ve: Code of Prac ce for Healthcare Records Management: Abbrevia ons: 2010, p. 4–6;
h p://goo.gl/e5EVnW. [29.02.2016]
3. Health Service Execu ve: Standards and Recommended Prac ces for Healthcare Records Management,
p.73–77; h p://goo.gl/UlR7UH. [29.02.2016]
4. John MacCarty: The GP referral le er- me for something new: 2010, h ps://goo.gl/CYEUIA [25.04.2016]
5. ICNP catalogues:
Nursing Diagnosis and Outcome Statements
Partnering with Individuals and Families to Promote Adherence to Treatment
Community Nursing
Nursing Interven on Statements
Paediatric Pain Management
Palla ve Care
  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on 41

ANNEX
In order to help you to improve your wri en language skills further, we have sourced some
addi onal medical forms with which you can prac ce. These forms cover a number of topics
such as hospital admission and discharge, which are relevant for working in any medical
environment.
To access these resources, please go to our website at h p://help-theproject.eu/moodle/
mod/page/view.php?id=700 to find the addi onal exercises.
42  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on

Module 2 Documentation – Medical Records,

Filling in Medical / Nursing Documentation
AUDIOSCRIPT

LISTENING 2
“Filling in a Nursing Admission Assessment form”.
A pa ent (Mrs. Black) has been brought into hospital with severe pains in her stomach. The nurse has the job of filling in the ini al
Assessment form. Below is the conversa on:

Nurse Hello I am Nurse White, please take a seat.

Mrs. Black Hello Nurse.
Nurse I understand you have pains in your stomach?
Mrs. Black Yes, it’s very painful. I didn’t get any sleep last night. I thought the pain would subside but it is ge ng worse.
Nurse That’s terrible, I will organise for a Doctor to see you as soon as possible.
Mrs. Black That would be great. Thank you.
Nurse In the mean me would it be ok if I could take some personal details from you?
Mrs. Black Yes, that’s fine.
Nurse Can you give me your full name please?
Mrs. Black My name is Mary Black, but I like to be called May.
Nurse So may I call you May?
Mrs. Black That would be fine, Nurse.
Nurse Great May. Can you tell me your address?
Mrs. Black I live in number 7 Green Street.
Nurse Can you tell me your date of birth?
Mrs. Black I was born on the 21st of January 1945.
Nurse That’s brilliant, do you have a home phone number?
Mrs. Black Oh yes, let me see, it’s 01 453 4949.
Nurse Do you have a mobile number by any chance?
Mrs. Black I do… but really don’t remember it. I can get my phone out of my bag.
Nurse No there’s no need I have your home phone number that will be sufficient, we can always get it later on.
Mrs. Black Ok nurse, thank you.
Nurse Are you currently working?
Mrs. Black No, I am re red, I used to be a hairdresser in Peter Marks it was very busy.
Nurse You must have really enjoyed working there.
Mrs. Yes it was wonderful.
Nurse Now May, do you have contact details for your Next of Kin?
Mrs. Black Yes, my daughter Jane Green, she lives in Lucan.
Nurse Do you have her address?
Mrs. Black Oh yes, it’s 24 Hilltop Avenue
Nurse That’s great, do you know her phone number?
Mrs. Black Oh, let me see, yes it’s 086 982 4554.
Nurse Is there anybody else who I can put down to contact?
Mrs. Black Oh yes, my Son, Roger Black.
Nurse That’s great, what’s his address and phone number?
Mrs. Black He lives in 27 Greencastle Road, but I don’t remember his phone number sorry.
Nurse Don’t worry maybe your daughter knows it. I can ask her when she comes in.
Mrs. Black Yes Jane will know it, or will have it on her phone.
Nurse That’s brilliant May, can you tell me who your Doctor is?
Mrs. Black Dr Murphy, Main Street, Lucan.
Nurse Yes his phone number is 01 234 2978. That’s great May, if you take a seat outside in the wai ng room a Doctor will
call you in a li le while.
  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on 43

LISTENING 3
“Best prac ce for healthcare documenta on – a lecture.”1

The hospital has recently employed a number of healthcare workers. As part of their introduc on they are asked to a end the
following lecture to ensure that procedures in recording documenta on are clear and of a high standard.

Lecturer: Good a ernoon everybody, today we are going to discuss the importance of quality clinical documenta on in the healthcare
records to ensure the con nuity and safe delivery of quality healthcare.
The general requirement for all entries in the healthcare record is to document and assist the communica on of care between pa-
ent, family and healthcare teams and provide proof of same. The record should contain enough informa on to iden fy the service
user, support the diagnosis, and jus fy treatment. It should also document the treatment course and results to aid con nuity of care
among healthcare providers.
To ensure correct iden fica on of pa ents, their name should be on each side of each page including their unique pa ent iden fica-
on number and/or iden fica on label. Always establish that the record belongs to the pa ent in a endance. This should be done
by verifying name and date of birth with the pa ent and for in-pa ents/day-cases by cross-referencing the pa ent’s iden ty band
with the healthcare record.
Records should be wri en in the language agreed by the healthcare organisa on, they should be phrased clearly, explicitly and be
devoid of jokes or rude remarks. When you fill in any documenta on the wri ng should be clear and legible. The date and me of
entry using the 24-hour-clock should always be clear on a healthcare record. If prescribing, wri ng should be legible lower case text or
block capitals. Medica on names should always be wri en in full and never abbreviated under any circumstances. Chemical symbols
should not be used.
When making correc ons, all dele ons or altera ons should be made by scoring out with a single line followed by a signature plus
name in capitals and counter signature, if appropriate. The date and me of correct entry and the reason for amendment. Correc ons
should be made as close to the original record as possible.
When recording retrospec ve entries (something that has happened in the past) the documenta on should be dated, med, using
the 24-hour-clock and signed with a clear signature, PRINTED NAME, job tle and iden fica on number if relevant and counter-signed
if appropriate. The reason why the retrospec ve entry is being made should be clearly stated. It should be clear that the entry is
a retrospec ve entry.
Abbrevia ons should be avoided if at all possible, only those approved by the healthcare organisa ons should be allowed. Abbrevia ons
should not be used in documenta on that is used for transfer or discharge of a pa ent, or communica on sent from the healthcare
organisa on, e.g. referral le ers, consent forms, death cer ficates and medica on sheets.
If any advice on care is given, in any format e.g. verbal or by presen ng a leaflet, it should be documented in notes as advice given.
That’s all for today. Does anyone have any ques ons?

VIDEO SCRIPT
“Falls Risk Assessment.”

A man who had suffered a stroke approximately six months ago has come to the out-pa ents.
Opening Scene: A man is in a room alone, sits on a chair. A Nurse walks in and introduces herself.

Nurse Good morning Mr. Doyle, my name is Nurse Ryan. I see from your notes that you suffered a stroke a few months ago,
is that right?
Mr. Doyle Yes, in March of this year.
Nurse This morning we are going to have a quick chat and ask you a few ques ons to see how you are doing moving around
and how steady on your feet you are. Is that okay?
Mr. Doyle Yes, that’s fine.
Nurse Have you had any fall since your stroke, Mr. Doyle?
Mr. Doyle Yes, I had a li le fall in the bathroom about 3 weeks ago.
Nurse So what happened?
Mr. Doyle I was ge ng up off toilet and just lost my balance, I fell on the floor. My wife got our next door neighbour Jack in to
help me get up. I was very lucky as I didn’t hurt myself so I didn’t need to go to the Doctor or Hospital.
Nurse Has the Occupa onal Therapist visited you home?
Mr. Doyle No, not yet.
Nurse Ok.

1 
Health Service Execu ve: Standards and Recommended Prac ces for Healthcare Records Management, 2011, p.73–77; h p://goo.gl/
UlR7UH. [29.02.2016]
44  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on

Mr. Doyle I purchased a raised toilet seat since the fall and it has really helped me when I am ge ng up off the toilet.
Nurse That’s great, so you haven’t fallen since?
Mr. Doyle No.
Nurse So you are able to use the toilet on your own?
Mr. Doyle Yes, I’ve been more careful when going to the toilet now.
Nurse How is your eyesight since your stoke?
Mr. Doyle I am fine, once I remember to put on my glasses!!
Nurse Ok, Mr. Doyle, if you could please stand up from chair?
Mr. Doyle I’ll give it a go, I some mes find it difficult to get up of the chair, and my wife usually gives me a hand.
Mr. Doyle is unable to get up (tries a number mes but fails) grun ng and groaning.
Nurse Ok Mr. Doyle, hold on I will give you a hand.
The Nurse comes over to give him a hand to get up.
Mr. Doyle Thank you Nurse, (sigh).
He then stands up using his walker to support himself.
Mr. Doyle Ok, I’m up (with an unsteady smile).
Nurse Now Mr. Doyle, can you please walk to the door, turn around and come back to the seat please.
Mr. Doyle With my walker?
Nurse Do you think you could do without it?
Mr. Doyle No, I don’t think I could do this, sorry.
Nurse Then by all means please use the walker.
Mr. Doyle proceeds very slowly to the door, and with great difficulty turns around to come back to the chair (a few grunts and groans).
Nurse Well done Mr. Doyle, now please take a seat.
Mr. Doyle Thank you.
Nurse That’s great Mr. Doyle. A er assessing your mobility I am going to make a referral to the Occupa onal Therapist to
come out and visit your home.
In the mean me I am going to give you this leaflet with informa on on how to prevent falls. It also includes ps on
how to help make you house safe for example loose rugs, poor ligh ng.
Mr. Doyle Thank you so much Nurse.
Nurse You are very welcome Mr. Doyle.
Mr. Doyle Bye, bye.
Nurse Goodbye, Mr. Doyle.
  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on 45

KEY TO EXERCISES

LISTENING 2
“Filling in a Nursing Admission Assessment form”.

NURSING ADMISSION ASSESSMENT

Biographical Data

Name: Age: (to be calculated by the student) Address:

Mary Black 7 Green Street

Date of Birth:
21/01/1945
Consultant: no info in the script

Preferred Name: Na onality: (not known) Telephone Numbers:

May
Home: 01 453 4949

Mobile:
Name of Next of Kin: Can the pa ent communicate in English?
Jane Green
Yes X  No 

If no what is their first language?

1. Name of first contact person: TELEPHONE:

Jane Green
Home: (not given)
Rela onship:
Daughter Work: (not given)

Mobile: 086 982 4554

2. Name of second contact person: TELEPHONE: (not given)
Roger Black
Home: (not given)
Rela onship
Son Work: (not given)

Mobile: (not given)

G. P. Name Telephone: ADDRESS
Dr Murphy 01 234 2978 Main Street, Lucan
46  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on

SPEAKING 1
Example of completed CONSENT FORM (for Laparoscopic Appendectomy).

CONSENT FORM
Pa ent Agreement to Inves ga on or Treatment

DETAILS OF PROCEDURE OR COURSE OF TREATMENT PROPOSED

Name of proposed procedure or course of treatment (include brief explana on if medical term not clear)
Laparoscopic Appendectomy – Removal of inflamed appendix

Site and Side of opera on or procedure

Appendix site – Lower right abdomen

Has site been marked?   X Yes    No    Not Applicable

Statement of Healthcare Professional

(to be filled in by Healthcare Professional with appropriate knowledge of the proposed procedure, as specified in consent form)

I have explained the procedure to the pa ent. In par cular I have explained:

Serious or frequently occurring risks such as:

Bleeding, infec on, injury to nearby organs, blocked bowels

Any extra procedures which may become necessary during the procedure
X Blood transfusion  other procedure (please specify)

________________________________________________________________________________
I understand that any procedure in addi on to those described on this form will be only carried out if it is necessary to save my life
or prevent serious harm to my health.
I have been told about addi onal procedures which may become necessary during my treatment. I have listed below any procedures
which I do not wish to be carried out without further discussion.

STATEMENT OF PATIENT
I agree to the procedure or course of treatment described on this form.
I understand that you cannot give me a guarantee that a par cular person will perform the procedure. The person will, however,
have the appropriate experience.

Pa ent’s signature: John Doyle Date: (today’s date)

Name (PRINT): Mr John Doyle

Signed Doctor: Dr Paul Ryan

Doctor’s Name (Please Print): Dr Paul Ryan
Job Title: Surgeon

READING 1
RULES FOR ABBREVIATIONS.

Q1 Choose at least three types of documenta on where you should never use abbrevia ons?

A1. Consent form; External referral le ers; Death Cer ficates; Medica on Sheets; Incident Report Forms.

Q2. Why should drug names never be abbreviated?

A2. To ensure that healthcare professional knows what medica on should be administered and get the correct medica on.
  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on 47

LANGUAGE FOCUS 1
TYPES OF FORMS.

1 Gathers informa on on a pa ent through interview and observa on on their physiological, Nursing Assessment Form
psychological, sociological, and spiritual status to assess their needs.
2 A report from the use of an ultrasound, computed tomography (CT) or nuclear medicine, Radiological Reports
positron emission tomography (PET) or magne c resonance imaging (MRI) which is used
to diagnose or treat diseases.
3 A record used to monitor input and output of fluids. Fluid Balance Chart
4 A chart is used to record vital signs and other clinical informa on in hospitals, and has a Pa ent Observa on Chart
key role in iden fica ng of pa ents who are deteriora ng.
5 A record of drugs prescribed or dispensed to a pa ent. Medicine / Drug Chart
6 To iden fy high falls risk for pa ents. Falls Risk Assessment Form
7 A record of facts rela ng to past and present health. Medical History Form
8 The results of laboratory examina ons, usually with analyses and findings. Laboratory Results
9 This is a form signed by a pa ent prior to a medical procedure to confirm that he or she Consent Form
agrees to the procedure and is aware of any risks that might be involved.
10 This form includes a diagnosis, procedures and follow-up arrangements, to be provided Discharge Summary
for the general prac oner (GP) on the discharge of a pa ent from hospital.

LISTENING 3
“Best prac ce for healthcare documenta on – a lecture.”

1. What are the general requirements for all entries in the healthcare record?

Answer:
The general requirements for all entries in the healthcare record is to document and assist communica on of care between pa ent,
family and healthcare teams and provide evidence of same.

2. What two ac ons should you do to ensure that you take care of the correct pa ent?

Answer:
The pa ent’s name should be entered on each side of each page including their unique pa ent iden fica on number and/or iden-
fica on label.
The healthcare professional should establish that the record belongs to the pa ent in a endance. This should be done by verify-
ing name and date of birth with the pa ent and for in-pa ents/day-cases by cross-referencing the pa ent’s iden ty band with the
healthcare record.

3. If wri ng in informa on that is retrospec ve what data do you need to include?

Answer:
For entries that are retrospec ve the documenta on should be dated, med, using the 24-hour-clock and signed with a clear signa-
ture, PRINTED NAME, job tle where relevant and counter-signed if appropriate.
There also needs to be a clear reason why the informa on has be added retrospec vely.
It also should be clear that the entry is a retrospec ve entry.

4. Name the two types of documenta on where abbrevia ons should not be used.

Answer:
 Transfer or discharge of a pa ent,
 Communica on sent from the healthcare organisa on, e.g. external referral le ers, consent forms, death cer ficates, medica on
sheets.
48  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on

LANGUAGE FOCUS 2
HOSPITAL DEPARTMENTS. Iden fy which department the person is a ending based on the informa on given below.

1 The person has been involved in a car accident. Accident & Emergency (A&E)
2 The person has recently suffered a heart a ack. Cardiology
3 The person has severe dermatosis. Dermatology
4 A person has recently had a brain injury which has le the person with mobility issues. Occupa onal Therapy
5 The person has been diagnosed with breast cancer. Oncology
6 The person has fallen off a wall, they landed heavily on their right arm which is very Radiology
painful.
7 The person is having difficultly speaking a er recently suffering a stroke. Speech & Language Therapy
8 The person has arthri s in her hands. Rheumatology
9 The person is suffering from blurred vision. Ophthalmology
10 The person requires tonsillectomy. Otolaryngology

VIDEO CLIP 1
Completed FALLS RISK ASSESSMENT FORM.

FALLS RISK ASSESSMENT FORM

Please complete Falls Risk Assessment on all pa ents over 65 years and on pa ents in specific risk groups (e.g. pa ents with Stroke,
Epilepsy, Head Injury).
Use this form to ideni y pa ents risk of falling.

FALLS RISK ASSESSMENT TOOL2

Answer the following ques ons: (please circle as appropriate)

1. Has the individual had a fall in the last six months? Yes = 1 No = 0

2. Is the individual agitated? Yes = 1 No = 0

3. Is the individual visually impaired that would effect everyday tasks? Yes = 1 No = 0

4. Is the individual in need of frequent toile ng?2 Yes = 1 No = 0

5. Is Transfer + Mobility Score 3 or 4? (see below) Yes = 1 No = 0

Risk Factor Assessment Score:

Transfer Score Mobility Score
0 = unable to transfer 0 = immobile
1 = major help need (1–2 people or hoist) 1 = independent with aid of wheelchair (or with 2 people)
2 = minor help needed (oral prompt to transfer) 2 = walks with help of one person (or with aid / aid and 1 person)
3 = independent with transfer 3 = independent
Transfer Score: 1 Mobility Score: 2 Add Transfer and Mobility Score: 3

Risk Factor assessment Score (add answers 1–5) = 2

N.B. SCORE OF ‘2’ OR MORE INDICATES A HIGH RISK OF FALLING

IF PATIENT AT RISK OF FALLING, PLEASE IMPLEMENT RISK OF FALLING CARE PLAN

Nurse Signature: Mary Ryan Date (today’s date)

2 
Toile ng means to assist or supervise a person in using the toilet.
  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on 49

LANGUAGE FOCUS 3
COMMON MEDICAL CONDITIONS.

1 Chronic Obstruc ve Pulmonary Disease E a collec on of lung diseases including chronic bronchi s, emphysema and
(COPD) chronic obstruc ve airways disease
2 Diabetes D is a long-term condi on caused by too much glucose, a type of sugar, in the
blood
3 A heart a ack A a serious medical emergency in which the supply of blood to the heart is sud-
denly blocked, usually by a blood clot
4 Asthma G a condi on that affects the airways
5 Chickenpox H a rash of red, itchy spots that turn into fluid-filled blisters
6 Cancer B a group of condi ons where the body’s cells begin to grow and reproduce in
an uncontrollable way
7 Flu C virus infects your lungs and upper airways, causing a sudden high temperature
and general aches and pains
8 Measles F a highly infec ous viral illness. It causes a range of symptoms including fever,
coughing and dis nc ve red-brown spots on the skin.

SPEAKING 4
Key informa on required in a Referral Le er:

Informa on Required for a Referral Le er:

• Personal Details – including DOB • Other Illness
• Signs and Symptoms • Treatment
• Results of Tests • Allergies
• Treatment Given • Family and Social History
• Probable diagnosis • Reason for Referral

WRITING 2
Using a case from your own experience, write a detailed Referral Le er.

Informa on Required for a Referral Le er:

Sec on 1: Addressee Sec on 4: Referral specific clinical informa on

Referral to: Consultant / speciality clinic/ hospital / address Reason for referral/comments:
Symptoms. History of presen ng complaint: Examina on Findings:
Sec on 2: Pa ent demographics / details Test results (if any):
Pa ent Details Laboratory inves ga on results (a ached, N/A, or summary)
First Name: Radiology inves ga on results (a ached, N/A, or summary)
Surname:
Gender: Sec on 5: General clinical informa on
DOB: Past medical history:
Address: Medica ons:
Name of parent or guardian if appropriate: Allergies/adverse reac ons to medica on:
Mobile No: Family history:
Tel day: Social history:
Tel evening:
Hospital No: Sec on 6 Referrer details
First Language: Referring general prac oner details
Interpreter required: Name:
Wheelchair assistance: Address:
Telephone:
Sec on 3: Priority Emergency contact/mobile:
Date of referral: Fax:
Referral source: (GP, ED, other) Medical Council registra on no:
Priority: (urgent, early, rou ne) GP signature:
Pa ent’s usual general prac oner- as above / or details below
Name:
Address:
50  HELP Module 2 Documenta on – Medical Records, Filling in Medical / Nursing Documenta on

IMAGE SOURCES
Doctor-1228627. h ps://goo.gl/cPfclP (CC0 1.0). [25.04.2016]
Doctor-784329. h ps://goo.gl/lPPXW0 (CC0 1.0). [25.04.2016]