Patients can request for a copy of their medical records and do have the right to read their medical records. Each medical institutions have policies to address these requests.

Patients are required to have written permission for release of medical information.

ANA (American Nurses Association) states, “documentation must be systematic, continuous, accessible, communicated, recorded, and available to all members of the health care team.”

Record: Patient’s record or chart is a confidential permanent legal documentation of the patient’s health care.

Record/Chart usually includes the following information:

Patient identification & demographic data

Informed consent for treatment & procedures

Admission nursing history

Nursing diagnoses or problems or multidisciplinary care plan

Record of nursing care treatment & evaluation

Medical history

Medical diagnosis

Therapeutic orders

Medical & health discipline’s progress note

Reports of physical examination

Reports of diagnostic studies

Patient education

Summary of operative procedures

Discharge plan & summary

For example: “Patient diaphoretic, B/P 80/50; HR 102 bpm and regular”.

For example: Patient’s intake, 360 mL of water.

Do not use vague statements: Patient drank an adequate amount of water. How is adequate defined?

2009 NATIONAL PATIENT SAFETY GOAL: Improve staff communication.

Create a list of abbreviations and symbols that are not to be used.

TJC has a list of “do not use” abbreviations.

For example:

Q.D. (each day) misinterpreted as QID (four times a day); Write daily.

MS, MSO, or MgSO confused with one another. Write-out Morphine Sulfate or Magnesium Sulfate.

Activities to communicate & document at the time of occurrence include the following:

Vital Signs

Administration of medications & treatments

Preparation for diagnostic tests for surgery

Change in patient’s health status and who was notified

Admission, transfer, discharge or death of a patient

Treatment for a sudden change in patient’s status

Patient’s response to treatment or intervention

PIE Note (Problem, Intervention, Evaluation)

Focus Charting (DAR) – (Data, Action, Response)

CBE can pose legal risk if nurses are not disciplined in documenting exceptions.

Patient’s Room Number

Physician’s Name

Diagnosis

Date of Surgery (if applicable), i.e. Post-op Day

Report of any unusual findings based on nursing assessment, i.e. significant changes in Vital Signs

Unusual responses to Treatments or Medications

Unusual Occurrences

Laboratory Studies

Tests to be completed on the next shift

Any Physical or Psychosocial Problems