Record In Health Care Essay

10.1 PURPOSE OF RECORDS This concept was taken from module 10 “Nursing information sub-topic 2”. “Nursing Records and Report”. In the hospital, records are known to be written information relevant to patient’s health care management. Records are what are used in writing down all information about a patient’s health status and treatments administered and the effect of the treatment and the outcome at last. The nurses in the hospital keeps records of their nursing care, the doctor’s document all treatment rendered, the laboratory department also do same for all investigations carried out on patients, the radiology department also do same. The other departments in the hospital e.g. maintenance department who are responsible for all repairs of hospital equipment also keeps records of all repairs carried out in each room. The facility department responsible for ensuring cleanliness in the hospital also keeps records of all activities carried out. The accounts department also keeps a record of all financial transaction in the hospital (both with patients and others in the hospital) etc. Nobody has a computer brain and as humans we are prone to forgetting hence the need for record keeping as it

Hence in recording we will be discussing its purposes;

CLINICAL PURPOSE OF RECORDS

1. Records help to improve patient care as it helps professionals to make an improvement based on information gotten from chat of patient health status.

2. Records provide information to other health professionals’ thereby assisting in continuity of care. It makes the person on the next shift to know what have being done and where to continue from.

3. Records help to serve as a memoir to the professionals during subsequent consultations. All we have to do is to check previous visits and get information of patient’s health conditions forming a case history.

4. Records help to store information reserved from other department e.g. results from