Medical record and

file arrangementRAHIMA M. SALENDAB, BSN, RN

NQMC, MGH, KSA

DEFINITION OF MEDICAL RECORD الطبي السجل تعريف

IMPORTANCE OF MEDICAL RECORD الطبي السجل أهمية

The required information in the medical record

سجل في المطلوب المعلوماتالطبي

1. Information relatED to patient and patient care rendered

مثل -1 به العناية او بالمريض صلة لها معلومات

2. Visual information from the nurse / personal information from the same patient 2 \ -نفسه المريض من شخصية الممرضة من مرئية معلومات

3. Information About the time and date

التاريخ- 3 و الوقت معلومات

4. Information on how to give treatment

العالج- 4 إعطاء معلومات

5. Information on verbal order

الشفهية- 5 األوامر معلومات

File

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REGISTRATION FORM 1DETAILED PATIENT INFORMATION 2ADMISSION / DISCHARGE FORM 3ADMISSION COVER SHEET 4ADMISSION SHEET 5ADMISSION ASSESSMENT FORM 6DISCHARGE SUMMARY FORM 7DISCHARGE FORM FROM ISTALAMAT (adaption Receipt of the patient, Patient information, Adoption of Discharge)

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DAMA FORM 9HISTORY/PHYSICAL EXAMINATION FROM 10ER PAPER 11DOCTORS ORDER 12NURSES NOTES 13MEDICATION SHEET 14TPR SHEET 15PAIN ASSESSMENT & REASSESSMENT FORM 16VIP (VISUAL INFUSION PHLEBITIS)SCORE FORM 17DIABETIC FORM 18CHANGE OF POSITION FORM 19SUMMARY OF LABORATORY RESULTS 20LABORATORY RESULT 21ECG MOUNTING 22REFERRALS 23CONSULTATION 24RESULT (U/S, CXR, CT SCAN, MRI, etc…) 25CONSENT 26OR PRE – OP CHECK LIST 27ANESTHESIA FORM 28POST – OP FORM 29TRANSFUSION DATA FORM 30PATIENT IDENTIFICATION FORM 31OTHERS 32

Models of nursing documentation in progress notes

1. Narrative documentation

نموذج في التوريضي التوثيق أنماطالتطور مالحظات

قصصي – 1 سردي بشكل التوثيق

DATE TIME PROGRESS SIGNATURE

01/01/1434

O7:30H

08:00H 08:45H

09:00H 12:30H

15:30H

- Received pt on bed awake, conscious and oriented, afebrile, with IV cannula size 22G in left arm, with ongoing IV Normal Saline 500 cc at the level of 200 cc, infusing well -------------------------------------------

- V/S checked and recorded ------------------------------- - Seen and examined by Dr. Musa with orders made

and carried out --------------------------------------------- - Blood for CBC extracted, sent to lab - Lunch served, ate with fair appetite -------------------- - To keep NPO post-midnight for possible OR

tomorrow --------------------------------------------------- M.E.

- Fax send to KFH for CT brain -------------------------- “Late entry” abdominal ultra sound done at 10:30H, report

seen by Dr. Musa --------------------------------- - Closely watched and attended --------------------- - Endorsed ---------------------------------------------------

A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi Amal AlHarbi

2. Problem oriented documentationتحديد – 1 بشكل التوثيق

المشكالت

Con’t

a. Method of (soap) or (soapie)

ال – السلوب ال( )soap)أ ( soapieأو

المريض من المأخوذة المعلومات S: subjective

المرضة قبل من المالحظة المعلومات O: objectivce

للمريض الصحية المشكالت A: assessment

العالج خطة P: planning

الخطة تنفيذ نشاطات i: intervention

المجريجات تقييم E: evaluation

a. Method of (soap) or (soapie) ال – السلوب ال( )soap)أ ( soapieأو

WHAT PATIENT TELLS YOU(COMPLAIN OF ABDOMINAL PAIN)

S: subjective

WHAT YOU OBSERVE, SEE(IS PALE AND HOLDING HIS/HER RIGHT SIDE)

O: objectivce

WHAT DO YOU THINK IS GOING ON BASED ON YOUR DATA(RECURRING ABDOMINAL PAIN)

A: assessment

WHAT ARE YOU GOING TO DO(CHECK V/S, PUT ON NPO AND NOTIFY PHYSICIAN)

P: planning

SPECIFIC INTERVENTIONS IMPLEMENTED i: intervention

PATIENT RESPONSE TO THE INTERVENTION E: evaluation

NO ONE CAN MOTIVATE YOU….

IF YOU ARE NOT WILLING TO DO YOUR SELF…

تكن ) لم إذا تحفزلك أن يمكن احد النفسك للقيام استعاداد (على

If you are not willing to learn, No one can Help you.

( , يستطيع ال للتعلم استعداد على تكن لم إذامساعدتك (أحد

If you are determined to learn, No one can stop you …!!!

( , ألحد يمكن ال التعلم على عازمة كنت إذا(....إيقافك

THANK YOU