OTHER SOURCES OF DATA

• Types of data in a patient's chart


  • Problem list
  • Emergency room admission sheet
  • Consent for admission, health care and diagnostic test procedures
  • Department of Pediatric general data
  • Progress notes
  • Vital signs sheet for patient under close observation
  • Intake and output
  • Physician's notes
  • Vital signs clinical chart
  • Medication and treatment record
  • Intravenous fluid sheet
  • Discharge summary
  • Nurses notes
• Problem list


  The healthcare provider writes all the problems noted, along with the date observed and date resolved. This paper is used to track all observed problems
• Emergency room admission sheet


  Contains the patient's database, chief complaints, and other pertinent information written upon admission
• Consent for admission, health care and diagnostic test procedures


  It is important to secure this consent form so that the patient cannot deny any hospitalization. Failure to obtain consent may result in the patient denying procedures, care, admission, and ultimately not paying for services rendered
• Department of Pediatric general data


  The doctor/healthcare provider can write the patient's complaints, history of present illness, and past medical history
• Progress notes


  The healthcare provider writes all the progress the patient has achieved during their hospital stay. This is essential for insurance payment. Doctors write daily progress notes during their visits
• Vital signs sheet for patient under close observation

  Contains vital signs monitored at intervals (e.g., 15 mins, 30 mins, every hour) for patients under close observation. Vital signs are crucial for tracking the patient's condition
• Intake and output


  Nurses monitor the patient's fluid intake and output through oral or parenteral routes. It is important for renal or cardiovascular conditions to prevent fluid retention
• Physician's notes


  Contains the doctor's orders for the patient. Nurses follow these orders for patient care, especially regarding diets, medications, and special procedures
• Vital signs clinical chart

  Graphs the patient's vital signs at specific intervals for tracking fluctuations. Doctors use this chart to monitor the patient's condition
• Medication and treatment record


  Nurses must initial given medications at specific times for tracking. Senior staff review the chart, and unsigned medications should not be considered administered
• Intravenous fluid sheet


  Nurses record the IV bottles administered until termination. This is crucial for tracking fluid intake and output
• Discharge summary


  Contains pertinent information written by the healthcare provider before billing the patient. It is a requirement for billing and insurance claims
• Nurses notes


  Nurses document pertinent information on problems, assessment, management, and patient response in the format of FDAR (Focus/Problem, Data, Action/Management, Response/Result)
• Documents in a healthcare setting

  • Problem List
  • Emergency Room Admission Sheet
  • Consent for Admission, Health Care and Diagnostic Test Procedures
  • Department of Pediatric General Data
  • Progress Notes
  • Vital Signs Sheet for Patient Under Close Observation
  • Intake and Output
  • Physician's Notes
  • Vital Signs Clinical Chart
  • Medication and Treatment Record
  • Intravenous Fluid Sheet
  • Discharge Summary
  • Nurses Notes
• Problem List


  • The healthcare provider will write all problems noted
  • Date, when was observed, date was resolved
  • Used to track all problems being observed by the healthcare provider
  • Helps know when problems are being resolved
• Emergency Room Admission Sheet


  • Contains patient's database, chief complaints, and other pertinent information that the examiner can write upon admission
• Consent for Admission, Health Care and Diagnostic Test Procedures

  • Secures consent so the patient cannot deny hospitalization
  • If not signed, the patient can deny procedures and not pay for services
• Department of Pediatric General Data


  • The doctor/healthcare provider can write the patient's complaint, history of present illness, and past medical history
• Progress Notes


  • The healthcare provider can write all the progress the patient has achieved during their stay
  • Basis for payment of insurance
  • If no progress, insurance may not pay
• Vital Signs Sheet for Patient Under Close Observation

  • Tracks vital signs for patients under 15 min, 30 min, or hourly monitoring
  • Allows doctors to easily track vital signs
• Intake and Output


  • Nurses must track patient's fluid intake (oral, parenteral) and output (drainage)
  • Important for managing fluid balance, especially for renal or cardiac patients
• Physician's Notes


  • Contains doctor's orders that nurses must follow
• Vital Signs Clinical Chart

  • Graphs vital signs taken at 12am, 4am, 8am, 12pm, 4pm, 8pm
  • Allows doctors to track fluctuations in vital signs
• Medication and Treatment Record


  • Nurses must initial each medication given at the specified time
  • Allows supervisors to review medication administration
• Intravenous Fluid Sheet


  • Nurses must record each IV bottle used until the IV is terminated
  • Allows tracking of IV fluids for intake and output
• Discharge Summary


  • Healthcare provider must write pertinent information before the patient is billed
  • Required for payment, including from insurance
• Nurses Notes


  • Nurses must write all pertinent information in the FDAR format (Focus/Problem, Data, Action/Management, Response/Result)
• Documents in a healthcare setting

  • Problem List
  • Emergency Room Admission Sheet
  • Consent for Admission, Health Care and Diagnostic Test Procedures
  • Department of Pediatric General Data
  • Progress Notes
  • Vital Signs Sheet for Patient Under Close Observation
  • Intake and Output
  • Physician's Notes
  • Vital Signs Clinical Chart
  • Medication and Treatment Record
  • Intravenous Fluid Sheet
  • Discharge Summary
  • Nurses Notes
• Problem List


  • The healthcare provider will write all problems noted
  • Date, when was observed, date was resolved
  • Used to track all problems being observed by the healthcare provider
  • Helps know when problems are being resolved
• Emergency Room Admission Sheet


  • Contains patient's database, chief complaints, and other pertinent information that the examiner can write upon admission
• Consent for Admission, Health Care and Diagnostic Test Procedures

  • Secures consent so the patient cannot deny hospitalization
  • If not signed, the patient can deny procedures and not pay for services
• Department of Pediatric General Data


  • The doctor/healthcare provider can write the patient's complaint, history of present illness, and past medical history
• Progress Notes


  • The healthcare provider can write all the progress the patient has achieved during their stay
  • This is the basis for payment by insurance
  • Doctors write daily progress of the patient
• Vital Signs Sheet for Patient Under Close Observation


  • Used to write all vital signs gathered for patients under 15 min, 30 min, or hourly monitoring
  • Helps doctors track vital signs from start to end of shift
• Intake and Output


  • Nurses must be aware of the patient's fluid intake (oral, parenteral) and output (drainage)
  • Important for monitoring fluid retention which could be fatal
• Physician's Notes


  • Contains the doctor's orders which nurses observe and follow
• Vital Signs Clinical Chart

  • Graphs the patient's vital signs gathered at 12am, 4am, 8am, 12pm, 4pm, 8pm
  • Doctors use this to track fluctuations in vital signs
• Medication and Treatment Record


  • Nurses must affix their initials on given medications at specific times
  • Supervisors review this to ensure medications were properly administered
• Intravenous Fluid Sheet


  • Nurses must write the IV bottle numbers until the IV is terminated
  • Used to track IV fluids for the Intake and Output