4. INTRODUCTION
An Electronic Medical Record (EMR) is a medical record in digital
format. This facilitates access of patient data by nurses at any
given location, building automated checks for drug and allergy
interactions, clinical notes and laboratory reports. The term
Electronic Medical Record can be expanded to include systems
which keep track of other relevant medical information. Although
an EMR system has the potential for invasion of a patient's
medical privacy.
5. DEFINITION
• 'A patient record system is a type of clinical
information system, which is dedicated to
collecting, storing, manipulating, and making
available clinical information important to
the delivery of patient care. The central focus
of such systems is clinical data and not
financial or billing information’.
IOM 1997
6. • ‘'A longitudinal collection of electronic health
information for and about persons; immediate
electronic access to person- and population-
level information by authorized users;
provision of knowledge and decision-support
systems that enhance the quality, safety, and
efficiency of patient care and support for
efficient processes for health care delivery. "
IOM 2003
11. DEFINITION
• The EHR means a repository of patient data in
digital form, stored and exchanged securely,
and accessible by multiple authorized users. It
contains retrospective, concurrent, and
prospective information and its primary
purpose is to support continuing, efficient and
quality integrated health care.
International Organization for Standardization
12. TYPES OF ELECTRONIC HEALTH
RECORD (EHR)
Automated Medical
Record
Electronic Health
Record
Computerized
Medical Record
(CMR)
Electronic Medical
Record
Electronic Patient
Record
16. – Medical Data Components
The identified medical data component of
EHR consists of referral, present complaint, i.
e. symptoms, past medical history, life style,
physical examination, diagnosis, tests,
procedures, treatment, medication and
discharge.
17. – Nursing Data Components
Nursing data component of EHR comprise
of nursing charting area and nursing care plan;
medication administration, daily charting,
physical assessment, and admission nursing
notes.
18. OTHER ELECTRONIC
RECORD DEVICES
• Personal Digital Assistants
• Computer Automated Cancer Detection
• Computerized Theatre Management
Application
19. • Personal Digital Assistants
Personal Digital Assistants popularly
known as PDA are literally handheld
computers that help patient management.
20. • Computer Automated Cancer Detection
Computer automated Cancer detection like
ThinPrep Processor Model 2000 or PAPNET
are used for identifying abnormal cells from a
series of digital images of PAP smears fed.
21. • Computerized Theatre Management Application
Theatre Management Applications
automatically record patient information like
demographic and financial data, visit history
with dates, procedures, performing and
attending providers, care records with clinical
highlights and patient status, surgical data
including proposed, type, actual, severity and
risks stored for reference in the event of future
surgical procedures.
23. DEFINITION
• Record is written or computer based used
for specific purposes in any form. The
process of making an entry on a client's
record is called recording, charting, or
documenting. A clinical record, also called a
chart or client record is a formal, legal
document that provides evidence of a
client's care.
24. Hospital Record
• Hospital records are the central focus of all
our activities in the collection and utilization
of clinical information. Since these are the
entry of events in a sequence form so that
the continuity of these activities can be
maintained. Every organization has its own
system of recording.
25. Medical Record
• A medical record is a clinical, scientific,
administrative and legal document relating
to patient care in which is recorded
sufficient data, written in sequence of
events to justify the diagnosis and warrant
the treatment and results.
26. Conti…
• It is a document of facts which contains
statement by trained observers of conditions
found, examinations and therapy application
and results, and indicates whether or not the
efforts of doctors, supplemented by hospital
and related facilities are in accordance with
reasonable expectations of present day
scientific medicine.
27. Nursing Record
• A nursing record system is the record of care
planned and/or given to individual
patients/clients by qualified nurses or other
caregivers under the direction of a qualified
nurse. Nursing record systems may be an
effective way of influencing nurse practice.
28. OBJECTIVES OF HOSPITAL RECORDS
• To review patient care, take appropriate
clinical decisions and to develop treatment
plans.
• To provide an archival and legally acceptable
record.
• To provide material for researchers.
• To act as a source of information for heath
administrators.
29. Conti..
• To enables for hospital auditing.
• To carry out the things in right possible
manner.
• For statistical purposes.
• To use for teaching and diagnostic
purposes.
• To use for legal purposes.
30. PURPOSES OF MEDICAL RECORDS
• To improve the patient care
• To serve to document clinical
case history
• It serves to avoid omission or
repetition
• Assists in continuity of care
• It serves as evidences in
medico-legal cases
• It supplies necessary
information to institute and
employees
• To document the type and
quality of work
• To furnish proof of type and
quality of care
• To protect hospital in legal
situations
• To evaluate proficiency of staff
• To help in future program
planning.
For Patients For Hospital
31. PURPOSES OF PATIENT RECORDS
Communication
Planning
client care
Statistical
and research
Auditing
health
agencies
33. FUNCTIONS OF RECORDS
• Helping to improve accountability.
• Showing how decisions related to patient care
are made.
• Supporting the delivery of services.
• Supporting effective clinical judgments and
decisions.
• Supporting patient care and communications.
34. Conti….
• Making continuity of care easier.
• Providing documentary evidence of services
delivered.
• Promoting better communication and sharing of
information between members of the multi-
professionals healthcare team.
• Helping to Identify risks, and enabling early detection
of complications,
• Supporting clinical audit, research, allocation of
resources and performance planning.
• Helping to address complaints or legal processes.
35. PRINCIPLES OF GOOD RECORD
KEEPING
• Handwriting should be legible.
• All entries to records should be signed. Put
the date and time on all records.
• Records should be accurate and recorded in
such a way that the meaning is clear.
• Records should be readable.
36. Conti…
• Records should be factual and not include
unnecessary abbrevlations, jargon, meaningless
phrases or irrelevant speculation.
• Record details of any assessments and reviews
undertaken.
• Include details of information given about care
and treatment.
• Records should identify any risks or problems
that have arisen and show the action taken to
deal with them.
37. Conti..
• Do not alter or destroy any records without
being authorized to do so.
• Do not falsify records.
• Be aware of the legal requirements and
guidance regarding confidentiality of the
records.
• Be aware of the rules governing confidentiality
in respect of the supply and use of data for
secondary purposes.
38. Conti…
• Follow organizational policy and guidelines
when using records for research purposes.
• Do not disclose the information and should
not leave any records, either on paper or on
computer screens.
• Be aware of, and know how to use, the
information systems and tools that are
available.
39. Conti…
• Ensure the proper use of the system
particularly in relation to confidentiality.
• Assess the standard of the record keeping and
communications.
40. CHARACTERISTICS OF GOOD
RECORDING
• The objectives of the records should be clear
and should be able to recognize the pertinent
factors like what to record? Will When to
record? Why to record? How to record? Who
will record?
• The records should be specific, concise to
purpose. There should not be any duplicity.
• There should be enough space to record.
41. Conti..
• Size of the record should be easily
approachable, it should be handy and such
that it will be easy to record and to handle.
• The design should be such that it would be
easy to complete and provide data which can
be used easily.
• The information should be recorded
immediately.
42. Conti..
• The language used should be legible, simple
and understood by the team members.
• The information should be accurate.
• Honesty should be there at the time of
recording.
43. Conti…
• The information recorded should be specific
and concise.
• Important events or activity may be depicted
predominantly with some indication.
• Arrange the records in an organized way.
44. STEPS FOR DESIGNING THE RECORD
• Following steps are followed in order to develop
or revise the format of any nursing record:
• Constitute a committee. The members should
be head of department, hospital administrator,
nursing head, supervisor and nursing staff of
operational level.
• Call a meeting and repeated meetings to seek
suggestions and prepare a rough draft of record.
45. Conti..
• Pretest it for its validity.
• Check the feasibility and utility by conducting
a pilot study.
• Periodically evaluate the record.
46. MAINTAINING OF RECORDS AND
REPORTS
• Be factual, consistent and accurate;
• Be updated as soon as possible after any
recordable event;
• Provide current information on the care and
condition of the patient;
• Be documented clearly in such a way that the
text cannot be erased;
47. Conti…
• Be consecutive and accurately dated, timed
and all entries signed.
• All original entries should be legible. Draw a
clear line through any changes and sign and
date;
• Not include abbreviations, slang or jargon as
not all workplaces or organisations will use
the same terminology;
48. Conti..
• Records must be stored securely and should
only be destroyed following your local policy;
• Avoid meaningless phrases, speculation and
offensive subjective statements/insulting or
derogatory language;
49. Conti…
• Identify the patient by recording patient’s
name, date of birth and hospital number on
each page of the record (three approved
identifiers) or follow your local policies on
how to identify patient’s records;
• Still be legible if photocopied or scanned.
50. RECORDS AVAILABLE IN NURSING
UNITS
TYPE OF RECORD RECORDS AVAILABLE
Nursing administrative
Ward policies, organization chart, procedure manual, stock
register indent books, list of equipment in use, drug book,
diet book, admission discharge books, report book etc.
Personnel
Job description personnel performance record, rotation
plan, duty roster, assignment book etc.
Clinical
Nursing care plan, nurses observation charts, nurses notes,
vital signs charts, intake output chart, drug chart, patient
file, identification chart, specific charts as per the unit etc
51. RECORDS AVAILABLE IN NURSING
OFFICE
TYPE OF RECORD RECORDS AVAILABLE
Nursing administrative Hospital policy manual, nursing policies,
organizational chart, nursing procedure manual etc
Personnel General: cumulative records, performance, personal
files etc
Personnel job descriptions of all categories
Personnel duty related records: duty roster, duty list,
roll call registers, allocation and leave forms etc.
Patients Hospital reports, census book etc
53. DEFINITION
• Report is oral, written, or computer- based
communication intended to convey information
to others. These can be formal or informal.
Reporting is the process of informing the other
staff about the patients and of other events.
54. Conti…
• Report is a summary of information. It is a
statement prepared to present facts relating
to planning, coordinating, performance and
the general state of services in an
organization.
55. OBJECTIVES OF REPORTS
• It presents factual information to
management and thereby serves as a means
of communication
• It provides a valuable record of documents,
which are, used in future reference.
• It provides necessary information to
department, clients and general public at
large.
56. PURPOSE OF REPORTING
• To communicate specific information to a
person or group of staff and to draw attention
to certain important events or facts.
58. Change-of-shift Report
It is a report given to all nurses on the next
shift. Its purpose is to provide continuity of
care for clients by providing a quick
summary of client needs and details of care
to be given to the on-coming staff.
59. Types of Change-of-Shift Reports
Bedside report
Written report
Verbal report
Change-of-
Shift
Reports
60. • Telephone Report
The nurse receiving a telephone report should
document the date and the time, the name of the
person giving the information, and the subject of
the information received. Telephone reports
usually include the client's name and medical
diagnosis etc. The nurse should have the client's
chart ready to give any further information. These
are usually flows from Nurse to physician Nurse to
nurse; Nurse to lab, dietary, etc.
61. • Telephone Orders
Physicians often order a therapy for a
client by telephone. While the primary care
provider gives the order, write the complete
order down and read it back to ensure
accuracy. Question any order if that is
ambiguous, unusual, or contraindicated by
the client's condition.
62. Transfer Report
• It includes the report related to:
• Unit to unit
• Summarize medical progress
• Background information
• Current status
• Current nursing diagnoses
• Critical assessments or interventions to be
completed shortly after transfer
• Special considerations
• Need for special equipment.
63. • Incident Reports or Occurrence Reports
These are the reports used to document
any unusual occurrence or accident in the
delivery of client care, such as falls or
medication errors. These reports are used for
quality improvement and should not be used
for disciplinary action against staff members.
Incident reports improve the management and
treatment of patients by identifying high-risk
patterns and initiating in-service programs to
prevent future problems.
64. • Conferring
These are the reports regarding
consultations and referrals, nursing care
conferences, nursing care rounds: procedures
done to obtain information that will help to
plan nursing care; provide clients the
opportunity to discuss their care; evaluate the
nursing care the client has received.
65. Intra-divisional
• Among Nursing Staff
This is about the patients, their condition,
number of patients, census, patients with
special problems, important that needs to be
reported taking and handing over.
66. • Between Nursing Sisters and Staff Nurses
Report of patients, handing and taking
over in the morning, during the round,
reporting about any incidence, diet, etc.
67. • Between Nursing Sister and Matron
Reports during evening and night shifts
about patients, serious patients, census,
vacant beds, events, staff on duty, any staff
member admitted, ward sanitation, family
planning cases, medico-legal cases, any
complaints, shortage of equipment if any,
absent staff, performance of staff.
68. • Between Nursing Sisters and Doctors
Nursing sisters do report. This is at the
time of round about the patients; during
the departmental meeting regarding the
requirement of wards, any complaints or
problem facing.
70. • Use Specific Descriptions
• Don't Erase, or Use Corrective Fluid
• Sequence
• Appropriateness
• Completeness & Conciseness
• Accepted Terminology
• Legal Prudence
71. LEGAL ASPECTS OF RECORDING
MAINTENANCE
• The patient’s records are occasionally
required as evidence before a court of law,
or to investigate a complaint at a local,
organization level.
• Sometimes records may be requested by
professional governing bodies when
investigating claims related to misconduct.
72. It is therefore critical to keep up-to-date with
the legal requirements and best practices of
record-keeping, proving that:
• A comprehensive nursing assessment of the
patient has been undertaken including care
that has been provided and planned;
• Relevant information is included together with
any actions that have been taken in response
to changes in patients’ conditions;
73. • The duty of care to the patient has been
provided and that no acts or omissions have
compromised a patient’s safety;
• Arrangements have been made for the
ongoing care of the patient.
74. CONCLUSION
• A patient record system is a type of clinical
information system, which is dedicated to
collecting, storing, manipulating, and
making available clinical information
important to the delivery of patient care.
The central focus of such systems is clinical
data and not financial or billing information.
75. EVIDENCE BASED PRACTICE
• Electronic patient records and innovation in
health care services
Abstract
The approach of today's EPR seems so
narrowly focused on automation of the existing
paper-based records by means of information
technology that it becomes obvious to raise the
question: ‘Will these automation efforts become
an impediment to innovation in products and
services in health care?’.
76. • This paper discusses how objectives like
improvements and innovations in products
and services in health care are met by means
of information technology (IT), and it argues
that a shift of focus from technological
innovation to innovation in products and
services is necessary in order to obtain
maximum benefit from IT.
77. • Health care quality management by means of
an incident report system and an electronic
patient record system
• Abstract
• Background: Quality management in health care
services has not been as successful as in other
industries.
• Objective: To assess the potential contribution of
an on-line incident reporting system (OIRS) and of
an electronic patient record (EPR) system to
quality management in hospitals.
78. • Methods: The two approaches are being
implemented in Osaka University Hospital.
• Conclusion: Direct data entry by medical staff
and an EPR based on dynamic templates and a
dynamic problem oriented approach could be
useful for building clinical data
repositories that can support clinical quality
management.
79. BIBLIOGRAPHY
• Jogindra vati; principles and practice of nursing management and
administration jaypee publications;648-655
• Deepak. k et al; A comprehensive textbook on nursing
management emmess publications;2013;555-559
• Basavanthappa B T;. Nursing administration. Ist edn. New Delhi:
Jaypee brothers;2000.
• Alamellu; Newer trends in management of nursing services and
education. health science publishers first edition 2017;
80. Net reference
• Electronic patient records and innovation in
health care services PB ELBERG - International
journal of medical informatics, 2001 – Elsevier
• www. pubmed.com
• www.wikepedia.com
• https://www.ausmed.com/cpd/articles/record-
keeping-documentation
