MEDICAL

CHART
What is Medical Record/Chart
The medical record is a legal document
providing a chronicle of a patient's medical
history and care. Physicians, nurse
practitioners, nurses and other members of
the health care team may make entries in the
medical record. The medical record includes
a variety of types of "notes" entered over
time by health care professionals, recording
observations and administration of drugs
and therapies, orders for the administration
of drugs and therapies, test results, x-rays,
reports, etc.
 Use of medical records
• To document the course of patient’s illness & treatment
.• Communicate between attending doctors and other health
Care professional providing care to the patient
• Collection of health Statistics.
• Filing of Medical records.
• Legal Matters & Court Cases
• Insurances Cases
• Retrieval of medical records for patient care and other
authorized use.
• Completion of medical records after an inpatienthas
been discharged or died.
• Coding diseases and operations of patients discharged or
having died
• Evaluation of the Medical Record Service.
• Completion of monthly and annual statistics.
• Medico-legal issues relating to the release of patient
information and other legal matters.
When the Chart is in your hand:

• FIRST: paginate it in the order it came from the hospital.

• Do not separate sections or pages.
• Do not take out pages you think may not be relevant.
• Begin to build a glossary and index.
• Do the chronology by going through each section
systematically.
Translate the Medical Terms
Medical translation:
➢ Is the translation of technical, regulatory,
clinical or marketing documentation, software
or training curriculums for the pharmaceutical,
medical device or healthcare fields.
Who is using it?
Hospitals across the country constantly require translation services
to ensure they offer fair treatment and a correct diagnosis of a
patient’s particular problem.

……and why is it so important?

It is extremely important to clarify the aspects of an ailment with a
doctor, and for a doctor to be fully understood by the patient as to the
details of their treatment. Should a specific therapy require an
explanation at length in a foreign language, a professional translator is
an invaluable resource.
Abbreviations:
1. It brings faster writing
2. It brings organization
3. World wide the same language. They are
many different ways to say the same thing.
4. It’s a standard way of communication
5. It is created to bridge the communication
6. Makes a clinical process easier
7. By using abbreviations, doctors and
nurses
Build Your Questions
• Who wrote? When? Why?
• Whose handwriting? Initials? Category?
• First mention of “query” – was it followed?
• Were signs overlooked? Thought about? Talked
about? Tracked? Trended? Treated?
• Sequential? Logical?
• Were assessments complete?
 Components of the Chart
Outpatient Records
▫ Emergency Room
Ambulance Report if the ambulance was used.
Time, method of arrival; Triage code, time of 1st
assessment, findings, diagnosis, time of disposition,
signatures.
▫ Tests
Non-stress Test (NST); cardiac stress tests; Ultrasounds, x-
rays; Pre-operative tests, ECG, blood work, diagnostic
imaging.
Inpatient Records
Admission/Discharge Record (2 Parts): Top
▪ Hospital name & #;
▪ Patient’s name & identification #; Patient’s
demographics; OHIP #; person to call in an
emergency; accommodation; Date & time of
admission;
▪ Diagnosis; attending physician.
01 04
Admission/Discharge Record: Lower half:
Completed at discharge:
• Date and time of discharge;
• Most responsible diagnosis at
admission;
• Complicating diagnoses arising after
admission;
• Other diagnoses present on
admission;
• Operations and procedures.
02 03
 15 Components of the Chart
1) Discharge Summary (MD);
2) Master Signature Record (Nurses);
3) History of present illness (HPI) & physical
examination (PE) on admission (MD);
4) Consultation Report (MD specialist);
5) Physician’s Orders (most responsible
physician -- MRP) dated, timed, & noted.
6) Operative Report (Surgeon);
7) Progress Notes (Interdisciplinary, not always);
Chronological.
8) Vital Signs Record (graphic) (Nurse);
9) Patient Care Plan (kept); Kardex (not always
kept);
10) Flow sheets (Nurse);
11) Medication Administration Record (MAR);
12) Patient Controlled Analgesia (PCA) Flow
Sheet;
13) Fluid Balance Record if IV fluids (hourly, 8-
hour, & 24-hour cumulative);
14) Laboratory Reports (cumulative, summary);
15) Monitor strips: Cardiac, fetal heart.
 COMPLETION OF MEDICAL RECORDS
• The consent form for treatment has been signed by thepatient;
• Patient identification details (name and medical record number)
are correct and entered onall forms
• Doctors have recorded all essential information
• Doctors have signed and dated all clinical entries
• The front sheet has been completed and signed by the attending
doctor
• Nurses have recorded and signed all daily notes regarding the
condition and care of the patient;
• All the orders for treatment have been recorded in the medication
form and signed;
• Medication administration has been recorded and signed
• The anesthetic form (if any) has been completed and signed
• The operation form (if any) has been completed and signed
• The main condition/principle diagnosis has been recorded on
the front sheet
• Operations and/or procedures have been recorded on the
front sheet
• Diagnostic reports have been attached
• Discharge/referral summary is duly filled and signed.
 Documentation Methods
1) Charting by Exception: is only appropriate when
assessment norms or standards of care are
explicitly written and available within the agency.
Never acceptable for medication administration.

2) Focus Charting – DAR (Data, action, response):

Problem oriented.
3) SOAP / SOAPIER: subjective (chief
complaint); objective (findings); assessment
(diagnosis); plan; implementation;
evaluation; revision
4) Narrative Notes: nursing interventions and the
outcomes of these interventions are recorded in
chronological order covering a specific time frame.
5) Critical Path & Variance Analysis Care Mapping
 Hospital Documentation Policies
• Provide direction to nurses to document the nursing care
provided and the process of clinical decision-making.
• Policies include:
▪ description of the method of documentation;
▪ expectations for the frequency of documentation;
▪ processes for “late entry” recording;
▪ listing of acceptable abbreviations;
▪ acceptance and recording of verbal and telephone orders; and
storage, transmittal, and retention of patient information.
 Flow Sheets—>Progress Notes
Decision Assessment Data

Normal? Abnormal?

Flow Sheet Flow Sheet &

Progress Notes
 Where is the chart kept?
Nurses’ Station?
•When is charting done?
•Who has access to the chart? Charting should
be contemporaneous.
Patient’s bedside? Separate Places?
Whole chart? • Lab reports, MD orders, nurses
Flow Sheets? notes?
Computer?
 Charting by
Exception
▪ Uses a care plan and standard protocols for that patient
situation;
▪ Cannot be used otherwise;
▪ ALL assessments & findings are charted on a flow sheet
(normal or not);
▪ ALL abnormal findings are detailed on a narrative
record (Focus, SOAP, narrative progress).
Narrative Record
Examples of Narrative Notes:

1) Focus charting (DAR)

2) SOAP or SOAPIER
3) Narrative
 What is FDAR?
Focus Charting:
Based on assessment – a patient concern;
Organizing structure:
D = Data (subjective & objective assessment);
A = Action or intervention done;
R = Response of the patient to the action or
intervention.
FDAR SAMPLE CHARTING
A
Date/Hour Focus Progress Notes
/20/20108:00pm Pain •D:Reports of sharp pain on the abdominal
incision area with a pain scale of 8 out of 10
•Facial grimacing
•Guarding behaviour
•Restless and irritable
B
A: C
•Administered Celecoxib 200mg IV
•Encouraged deep breathing exercises and
relaxation techniques
•Kept patient comfortable and safe
R: B
•Patient reports pain was relieved
A
C
SOAP format:
A problem-oriented approach – charting is
according to the problem.
Organizing structure:
S = Subjective data;
O = Objective
A = Action or intervention;
P = Plan
 SOAPIER format:

∿ S = Subjective data (What the patient says)

∿ O = Objective data (Exam, lab, vital signs)
∿ A = Assessment (diagnosis);
∿ P = Plan (Revision in plan needed?)
∿ I = Intervention (Actions taken by the provider.)
∿ E = Evaluation (The result of the action.)
∿ R = Revision (Changes in care plan needed?)
 Narrative Record
• Progress Notes.
• Chronological sequence of assessments,
actions, and responses.
• May stand alone or
• May be supported by flow sheets.

_____
Temperature, Pulse, and Respiration (TPR)
and blood pressure are called vital signs because they
must all be within normal limits to sustain life. In
addition, pain is considered to be the fifth vital sign.
Pain is to be assessed each time the other vital signs
are measured.
A PICTURE IS WORTH A
THOUSAND WORDS
THE GRAPHIC RECORD
The graphic record is a flow sheet used to easily
document large amounts of information for all
members of the healthcare team to read. Usually the
graphic record documents measurements of vital
signs, fluid intake and output (I&O), weight, and bowel
movements, assessed at regular intervals. In some
facilities, a paper graphic record is kept in the client’s
chart. In most acute-care facilities, this information is
entered into the electronic record.
Recording Vital Signs
Vital signs must be recorded accurately and promptly to
provide continuous and current documentation. A record
of a client’s vital signs helps providers diagnose and
respond to the client’s changing condition. It also serves
as a quick and handy reference for the entire healthcare
team.

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by Slidesgo, including icons by Flaticon, and
infographics & images by Freepik
The nurse needs to know the format for documenting vital
signs in his or her agency. Steps for recording vital signs in
the paper record include:

▪ Locate the current date on the graphic record.

▪ Record temperature by making a dot on the scale
parallel to the temperature value under the designated
time. Connect the dot to the previous reading with a
short line. (In many facilities using a paper record, the
CREDITS: This presentation template was created

temperature
& images by Freepik and pulse are graphed in different color
by Slidesgo, including icons by Flaticon, and
infographics

inks.)
Frequent Vital Signs
Sometimes a client’s condition is serious enough to require
taking vital signs every 5, 10, or 15 minutes. The frequent
vital signs sheet may be a paper document (most often in
critical care areas, after surgery, or in the immediate
postpartum period). Graph vital signs in the same way on
the frequent vital signs sheet as you would on the regular
record. In many cases, space is available to record other
information, such as intravenous (IV) fluids, I&O, weight,
medications, and notes. Frequent vital signs are entered on
the computer in a similar manner.
 Forms for Recording Data
Kardex
Flow Sheets
Nurses’ Progress Notes
Discharge Summary
Kardex
◊ is used as a reference throughout the shift and
during change-of-shift reports.
◊ Client data (e.g name, age, admission date, allergy)
◊ Medical diagnoses and nursing diagnoses
◊ Medical orders, list of medications
◊ Activities, diagnostic tests, or specific data on
the pt.
▪ Provides a concise method of organizing and Provides a
concise method of organizing and recording data about a client,
making information recording data about a client, making
information readily accessible to all members of the health
team. readily accessible to all members of the health team.
▪ It is a series of flip cards usually kept in portable file.
▪ It is a way to ensure continuity of care from one shift. It is a
way to ensure continuity of care from one shift to another
and from one day to the next.to another and from one day to
the next.
▪ It is a tool for change – of – shift report. But it is a tool for
change – of – shift report. But endorsement is not simply
reciting content of kardex. endorsement is not simply
reciting content of kardex. Health care needs of the client is
still primary basis for Health care needs of the client is still
primary basis for endorsement. endorsement.
 Do you have any questions?

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