9.6 : Types of Records I: Unit and Nurses Records

Unit records in healthcare settings document the patient's treatment history, including interventions, medications, diagnostic and laboratory results, progress notes, personal care needs, vital signs, and other medical information. They are crucial for managing patient care, aiding healthcare professionals in providing quality treatment and informed decision-making.

Unit records can be divided into two main types: administrative records and clinical records.

Administrative records in healthcare settings encompass documents and paperwork for patient care organization and finances. These records are vital for facility operation and administrative task management. Common types of administrative records in healthcare include:

• Appointment Bookings: Schedule and organize patient visits for efficient resource utilization and timely care delivery.
• Insurance Paperwork: Document patient insurance information, facilitating billing and reimbursement processes.
• Billing Statements: Track patient charges and payments, ensuring accurate financial records and billing compliance.
• Admission/Discharge Forms: Record essential patient admission and discharge information.

Clinical records offer comprehensive details, including a patient's diagnosis and treatment plan. This type of record includes essential components:

• Provider's Notes: Capture healthcare provider assessments, diagnoses, and treatment plans for a comprehensive patient's condition and management overview.
• Diagnostic and Laboratory Results: Include test findings, imaging studies, and other reports to aid diagnosis, monitor disease progression, and evaluate treatment effectiveness.
• Medication Records: Track prescribed, administered, and discontinued medications to ensure safety adherence and monitor potential drug interactions or adverse reactions.
• Surgery Reports: Outline surgical procedures, including pre-operative assessments, intra-operative findings, and post-operative care plans.
• Physical Therapy Plans: Outline rehab goals, exercises, and interventions for physical therapy patients to support recovery and functional improvement.
• Nutrition Plan: Specify dietary requirements or restrictions based on the patient's condition or treatment to promote nutritional support and manage comorbidities.
• Discharge Instructions: Guide post-discharge care, medications, follow-up appointments, and self-management strategies to enhance patient education and continuity of care.

Clinical records provide transparency of a patient's journey through the continuum of care. With this information, providers can develop an informed patient care plan.

Nursing records provide a comprehensive overview of the care supplied by the nurse and include vital information such as:

• Patient Medical History: The summary includes medical history, surgical history, allergies, medications, and past treatments so nurses understand the patient's background to provide patient-centered care.
• Medication Administration Records: Track medication administration times, dosages, routes, and patient responses for safe and effective drug therapy management.
• Communication Logs: Document interactions among nurses, patients, and healthcare providers to facilitate coordination, collaboration, and continuity of care.
• Patient Care Instructions: Record healthcare provider directives and education efforts, empowering patients to participate in their care and adhere to treatment plans.
• Quality Assurance and Legal Documentation: Provide evidence of nursing interventions, patient outcomes, and adherence to care standards: support quality improvement, legal proceedings, and insurance claims.

Nurses' records also document communication between the nurse and other healthcare professionals, and patient care instructions given by the physician or other healthcare professionals. Furthermore, they track patient outcomes and support education, research, legal documentation, and insurance claims.