B.

INGGRIS II
Lectured by:
Mrs. Nita Yuanita, S.Pd., M.Si.
Mr. H. Yun Surtiana, MA

PRODI S1 KEPERAWATAN
STIKES KARSA HUSADA GARUT
 B. INGGRIS II
UNDERSTANDING MEDICAL RECORDS
In this part, you will be reading examples of nurses’ notes and records.
The following text is in the form of MEMO addressed to the doctors,
nurses and paramedics at a hospital from the
hospital’s Medical Director.

Read and comprehend its meaning!

 B. INGGRIS II
MEMO TO ALL MEDICAL STAFF
Guidance for taking notes and keeping records
From the Medical Director

A number of problems are occurring throughout the hospital because some

staffs are keeping inaccurate and insufficient records of observations,
assessments and treatments.

I want to draw attention of all staff to the importance of good record-

keeping and ask everyone to read these guidelines

...
 B. INGGRIS II
Principles:
 Records primarily serve the interest of the patient
 Records should be an accurate chronology of events, recording all
consultations, assessments, observations, decisions and outcomes
 Records are essential mean of communicating among staff
 Records show that everyone has fulfilled his/ her duty of care

...
 B. INGGRIS II
Practice:
• Use black ink to make photocopying easier
• Write clearly and without spelling mistakes
• Print your name underneath your signature
• In your records highlight any important abnormalities.
• Use only abbreviations which are in common in this hospital
• Document all care as soon as it is given
• If you think that a patient has been involved in an assault or self-harm,
make a note of this to warn others
• Records if the patients is in the custody of the police
• Use rating scales to assess levels of pain, etc. which are in common use
throughout the hospital
 
 B. INGGRIS II
EXERCISE 1
Answer the following questions to check your understanding to the
MEMO from Medical Director above!
1. Inaccurate and insufficient is closest in meaning to:
a. bad and weak
b. wrong and not enough
c. unclear and too complicated
2. To draw the attention is to:
a. make a picture of the problem
b. highlight something
c. explain something
 B. INGGRIS II
... EXERCISE 1
3. A chronology of events is:
a. a record of the important things
b. a record of the time when things happen
c. a record of how long it takes for each thing to happen
4. Important abnormalities are:
a. significant mistakes
b. relevant problems
c. the usual things
 B. INGGRIS II
... EXERCISE 1
5. Things that are in common use in the hospital are:
a. only known by patients
b. understood by all staff
c. understood by all laymen
6. In the custody of the police mean:
a. employed by the police
b. protected by a bodyguard
c. under arrest
 B. INGGRIS II
The Need for Good Records:
Anything that makes reference to a patient,
such as a care plan or diary, can be used as
evidence in a law court. Care plans and diaries
are used, for example, when investigating
complaints of medical negligence or professional
misconduct
 B. INGGRIS II
Now, take a look to the sample of Patient’s Care Plan Record
below, then read and answer the questions!
Patient’s Problem Goals Nursing Instructions
Poss. Pressure sores Healthy a. Change position every 2h, straighten
due to poor skin. , intact sheets, remove crumbs (if any) use
Because of arthritis skin draw sheet. 2 nurses to turn patient
& previous b. Personal hygiene – keeps skin clean
radiotherapy – and dry. Assist with daily bed- bath.
general immobility N.B. hair & nails
c. Encourage nourishing diet with
adequate protein and at least 2l fluid
 B. INGGRIS II
EXERCISE 2
PROBLEMS
1) According to the notes, pressure
sores may be caused by the
patient’s:
2) The patient:
a. arthritis and radiotherapy
a. is having radiotherapy
b. inability to move
b. may have radiotherapy
c. dermatological problems
c. has had radiotherapy
 B. INGGRIS II
...EXERCISE 2
GOALS
3. The nursing goals are to:
a. Keep the patient’s skin healthy
b.Get the patient’s skin healthy
c. Get the patient healthy with skin intact
 B. INGGRIS II
...EXERCISE 2
NURSING INSTRUCTIONS
4. According to the “Nursing Instructions”, which of these
statements are true? Nurses must:
a. Change position every two hours
b. Move the patient every two hours
c. Help each other give the patient a bed-bath
d. Help the patient give herself a bed-bath
e. Keep their skin clean and dry
f. Not pay too much attention to the patient’s hair and nails
 B. INGGRIS II
END SECTION

THAN
K
YOU