Patient Chart: What it is
Definition
A confidential, detailed and comprehensive record about a patient and his experience with care (Krapp & Cengage, 2006) in a particular setting e.g. hospital, outpatient clinic, etc.
Purpose
To provide a medical and legal record of patient events in hospital i.e. clinical condition such as diagnosis, co-morbidities, clinical investigations, interventions and response to treatment and any other relevant information impacting the patient’s clinical status or outcome of current treatment e.g. religious beliefs about treatments.
Description
A patient chart is a collection of information regarding a particular patient. Physicians, nurses and members of the interdisciplinary team document in the chart and provides a way by which disciplines communicate about a patient.
Chart Systems
The Need for Chart Order
Definition
A confidential, detailed and comprehensive record about a patient and his experience with care (Krapp & Cengage, 2006) in a particular setting e.g. hospital, outpatient clinic, etc.
Purpose
To provide a medical and legal record of patient events in hospital i.e. clinical condition such as diagnosis, co-morbidities, clinical investigations, interventions and response to treatment and any other relevant information impacting the patient’s clinical status or outcome of current treatment e.g. religious beliefs about treatments.
Description
A patient chart is a collection of information regarding a particular patient. Physicians, nurses and members of the interdisciplinary team document in the chart and provides a way by which disciplines communicate about a patient.
Chart Systems
- Vary across institutions and even within an institution but almost all charts have universal aspects (Krapp & Cengage, 2006):
- Admission particulars: demographics, consent for admission and contact information;
- History and physical: notes on the medical history, reason for admission and physical exam;
- Patient care orders: treatment and medication orders written by physician, nurse practitioner or other professionals qualified to do so;
- Medication administration record;
- Procedures and tests: record of any procedures done during the admission;
- Progress notes: notes made by the multidisciplinary team on the patient’s daily current status during the admission;
- Consultation notes: notes from specialists who were consulted during the admission;
- Consents: documentation of permission provided by the patient to undergo particular tests and procedures;
- Flow charts: may contain tables or charts detailing certain aspects of patient care such as vital signs;
- Care plans: action plans for treatments during admission and upon discharge; Miscellaneous: other pertinent information that does not fit into any particular category but is important for patient care during the admission; and
- Charting systems may contain additional categories depending on the institution or service. For example, an oncology center may contain a special chart section on chemotherapy and radiation therapy while a palliative care unit may contain a special section on symptom assessment.
The Need for Chart Order
- Patient charts are an important source of information which facilitates the work and collaboration of health professionals towards best patient outcomes (Lingard et al., 2007).
- Collecting, transferring, deliberating and utilizing the information in a patient’s chart is an integral part of communication between health care professionals (Lingard et al.).
- "The way information is gathered, stored, transferred and negotiated – the way information is ‘worked with’ – underpins and shapes the other layers of team work that may be more obvious: threads of patient work, professional work, and technical work that must come together to provide effective collaborative care” (Lingard et al., 2007, p. 658).
