Nursing Records In Nursing

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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…show more content…
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
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This statistics contains patient’s name, sex, age, address, diagnosis, hospital number, consulting doctor, admitting nurse, date of admission, discharging nurse, date of discharge and condition at discharge. Every patient admitted is entered into the admission and discharge register and at the end of the admission and discharge register and at the end of the month I tally it up to know total number of admissions for the month, total number of male and female patient, number of deaths, and total number of medical cases, surgical cases, communicable diseases. The hospital uses this statistics to make improvement.

10.5 SIGNIFICANCE TO NURSING PROFESSION Record keeping is significance to the nursing profession as it helps us to know where to make improvement in the profession. It helps us to know where we are lacking so that we can make adjustments through training. Record keeping helps the nursing profession in research work.

10. 6 RECENT RESEARCH Research shows that records especially medical records help the health care providers to determine the patient’s health history and give appropriate care. The record help to plan patient’s care and also helps the health institutions in ensuring

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