CLIENT’S RECORD/

PATIENT’S CHART

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DESCRIPTION
• Client record ( chart,
clinical record) – is a
formal, legal document that
provides evidence of a
client’s care.
• - composed of printed
materials or an EMR
(Electronic Medical Record)
or combination of both

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Client’s Record is necessary for:

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Purposes of Client Records
1. Communication
 Serves as a vehicle by which different
health professionals who interact with
a client communicate with each other
 This prevents fragmentation, repetition,
and delays in client care

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 Purposes of Client Records
2. Planning client care
 Nurses use baseline and ongoing data to
evaluate the effectiveness of a nursing
care plan
 Each professionals uses data from the
client’s record to plan care for the client

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 Purposes of Client Records
3. Auditing health agencies
 An audit is a review of client records for
quality assurance purposes
 Accrediting agencies (such as JCAHO)
may review client records to determine if
a particular health agency is meeting its
stated standards

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Purposes of Client Records
4. Research
 The information contained in a
record can be a valuable source of
data for research
 The treatment plans for a number
of clients with same health
problems can yield information
helpful in treating other clients

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Purposes of Client Records

5. Education
 Students in health disciplines often
use client records as educational tools.
 A record can frequently provide a
comprehensive view of the client, the
illness, effective treatment strategies,
and factors that affect the outcome of
the illness

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 Purposes of Client Records
6. Reimbursement
 Documentation also helps a facility receive
reimbursement from the government
 The client’s record must contain the correct
diagnosis-related group (DRG) codes, which
reveals that the appropriate care has been
given. This will enable the facility to obtain
payment through Philhealth, or from insurance
companies and other third-party payers.
 Accurate, thorough recording by nurses will
facilitate reimbursement from these agencies

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 Purposes of Client Records

7. Legal documentation
 The client’s record is a legal document
and is usually admissible in court as
evidence
 It may be considered inadmissible as
evidence when the client objects,
because the information the client gives
to the physician is confidential

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Purposes of Client Records
8. Health care analysis
 Information from records may assist
health care planners to identify agency
needs, such as overutilized or
underutilized hospital services
 Records can be used to establish he
costs of various services and to identify
those services that cost the agency
money and those that generate revenue

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Components of a
Client’s Record

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 COMPONENTS OF A CLIENT’S CHART
1. Admission (face) sheet/ slip/ Clinical Cover Sheet
2. Consent forms for care
3. Nurse’s Admission Assessment
2. Medical History and Examination
3. Health Care discipline’s records
4. Physician’s Progress Notes
5. Physician’s Order Sheet
6. Operative and procedures report if performed incl
Anaesthesia, labor, delivery, therapy assessments etc
7. TPR Graphic Sheet/ Flow Sheet/ monitoring sheets
8. Medication/ Treatment Records
9. Nurses’ Notes
10. Discharge summary, discharge instructions etc

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 Components of a
Patient’s Chart
Admission (face) sheet
 Legal name, birthdate,
age, gender
 Social security number
 Address
 Marital status; closest
relatives or person to
notify in case of
emergency
 Date, time, and admitting
diagnosis
 Food or drug allergies
 Name of admitting
(attending) physician
 Insurance information (if
any)
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 Components of a Patients Chart
Consent forms
for care,
treatment and
research, when
applicable

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 Components of a Patients Chart
Medical History and Examination
 Results of initial examination performed by
physician, including findings, family history,
confirmed diagnosis, and medical plan of care

Nurse’s Admission Assessment

 Summary of nursing history and physical
assessment

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 Components of a Patients Chart
Health Care discipline’s records
 Entries made into record by all health-related
disciplines: radiology, social work, and laboratories
 Results of all laboratory tests performed.
 Results of all X-ray examinations performed.

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• Operative and procedures report including
preoperative and postoperative diagnosis,
description of findings, technique used, and
tissue removed or altered, if surgery was
performed.

• Anesthesia record including preoperative

diagnosis, if anesthesia has been
administered.

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Components of a Patient’s
Chart
5. Physician’s Order Sheet
 Record of physician’s
orders for treatment and
medications, with date,
time and physician’s
signature
6. Physician’s Progress
Notes
 Ongoing record of
client’s progress and
response to medical
therapy and review of
the disease process

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7. Graphic Sheet/ Flow Sheet/
Monitoring Sheet
 Record of repeated
observations and
measurements such as
vital signs, daily weights,
and intake and output

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8. Medication Records/
Treatment Records
 Accurate
documentation of all
medications
administered to client:
date, time, dose,
route, and nurse’s
signature

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5. Nurses’ Notes
 Narrative record of nursing process: assessment, nursing
diagnosis, planning, implementation, and evaluation of care
 FDAR, SOAPIE

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9. Discharge summary
 Summary of client’s
condition, progress,
prognosis,
rehabilitation, and
teaching needs at time
of dismissal from
hospital or health care
agency

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LEGAL RESPONSIBILITIES OF A
NURSE

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 POLICY / PROCEDURES
I. Maintenance of the Medical Record
A. A Medical Record shall be maintained for every individual
who is evaluated or treated as an inpatient, outpatient, or
emergency patient of a hospital, clinic, or physician’s office.

B. Original Medical Record documentation must be sent to the

designated Medical Records department or area. Whenever
possible, the paper chart shall contain original reports.

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II. Confidentiality
a) The Medical Record is confidential and is protected from
unauthorized disclosure by law.

III. Content
b) all hospital records and hospital-based clinic records must
comply with the applicable hospital’s Medical Staff Rules and
Regulations requirements for content and timely completion

c) All Medical Record entries should be made as soon as

possible after the care is provided, or an event or observation
is made. An entry should never be made in the Medical Record
in advance of the service provided to the patient. Pre-dating or
backdating an entry is prohibited

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a) All documentation and entries in the Medical Record, both
paper and electronic, must be identified with the patient’s full
name and a unique Medical Record number. Each page of a
double-sided or multi-page forms must be marked with both
the patient’s full name and the unique Medical Record
number, since single pages may be photocopied, faxed or
imaged and separated from the whole.

IV. Who May Document Entries in the Medical Record:

Multidisciplinary Notes
b) Only the following types of employees and/or employees of
contracted clinical and social services providers may
document entries in the Multidisciplinary Notes section of the
Medical Record

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V. Routine Requests for Medical Records for Purposes of
Treatment, Payment and Healthcare Operations

a) Healthcare providers who are directly involved in the care of

the patient may access the full Medical Record
b) Authorized and designated workforce members may access
the patient’s medical record for purposes of obtaining
payment for services
c) Patient medical records may be accessed for routine
healthcare operation purposes, including, but not limited to:
1. Peer Review Committee activities;
2. Quality Management reviews including outcome and
safety reviews;
3. Documentation reviews; and
4. Teaching.

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VI. Ownership, Responsibility and Security of Medical
Records

a) The information contained within the Medical Record must

be accessible to the patient and thus made available to the
patient and/or his or her legal representative upon
appropriate request and authorization by the patient or his
or her legal representative.

b) Original records may not be removed from facilities and/or

offices except by court order, subpoena, or as otherwise
required by law.

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VII. Maintenance and Legibility of Record

a) Handwritten entries should be made with permanent black or

blue ink, with medium point pens. This is to ensure the quality
of electronic scanning, photocopying and faxing of the
document. All entries in the medical record must be legible to
individuals other than the author.

VIII. Corrections and Amendments to Records

b) When an error is made in a medical record entry, the original
entry must not be obliterated, and the inaccurate information
should still be accessible
c) If information in a paper record must be corrected or revised,
draw a line through the incorrect entry and annotate the
record with the date and the reason for the revision noted,
and signature of the person making the revision.
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VIII. Corrections and Amendments to Records
a) Once a transcribed document is final, it can only be corrected
in the form of an addendum affixed to the final copy as
indicated above. Write “addendum” and state the reason for
creating the addendum, referring back to the original entry.

b) When a pertinent entry was missed or not written in a timely

manner, the author must
1. identify the new entry as a “late entry”
2. Enter the current date and time – do not attempt to give the
appearance that the entry was made on a previous date or an
earlier time. The entry must be signed.
3. Identify or refer to the date and circumstance for which the
late entry or addendum is written.
4. When making a late entry, document as soon as possible.
There is no time limit for writing a late entry; however, the longer
the time lapse, the less reliable the entry becomes. www.company.com
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QUESTIONS

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