Definition of "Health record"

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Health record is health data and information relating to the care of a patient. ED (or trauma) notes are records authored by the ED (or trauma) team. GP case notes are record authored in a GP consultation.

Electronic health record is where this information is collected in a digital format that can be theoretically shared across different health care settings.

Personal health record is where this information is collected and maintained by the patient (or the patient's parents). Blue book is a personal health record provided by the government to all newborn babies, and maintains all consultations with health professionals, developmental checklists, and vaccination history.

Source: Contents of the Blue book

Medical abbreviations are short hands used in medicine.

Source: NSW Health

Patient label

Patient label is a printed sticker with the Pt's uniquely identifying information, and can be affixed to forms instead of manually having to fill them out. It includes:

  • Unique barcode
  • Name of the hospital, and LOCATION/WARD name
  • Pt's MRN (Medical record number)
  • Pt's M/C (Medicare number)
  • H/F (Health fund), the private insurer number
  • Pt's surname in capital letters, first name in normal case
  • Pt's D.O.B. (date of birth), age, and gender
  • Address, PH (phone number)
  • M.O. (medical officer) responsible
  • ADM (date admitted)
  • Date the label was printed
  • FIN (financial), which for public hospitals is "Non-Charge/Public"

All paperwork will also provide the opportunity to insert:

  • Contains the title of the form ("Shoulder dystocia management") and unique identifier of the form (including catalog number)
  • Affix the Pt label
  • Circle facility name (i.e. a hospital may have several branches)
Progress notes

Progress notes (aka Clinical notes) paperwork includes:

  • Affix Pt labels
  • Document is presented like a classic school page like format, with a margin on the LHS, which is for insertion of Date and Time (use 24 hr clock)
  • There is a note that All entries must be legible, written in balck pen and include the health care provider's printed name, designation and signature. The document is otherwise just a page with lines
  • At the bottom of the page, includes AMO___ (attending medical officer) I attest that I have reviewed the notes, including Signed and Date
  • The form indicates which is Page 1 of 2, and which is 2 of 2
Handover

Paperwork for "Patient safety handover checklist pediatric" includes:

  • Affix Pt label
  • Mention that, All sections must be completed at the Pt's bedside with handover nurse at the end of each shift. Handover will utilize the ISBAR Handover framework. A variance and any action taken as a result of this process must be documented in Pt's progress notes. Medication incidents  entered in IIMS. Please mark Y=Yes, or N=No in all appropriate boxes and initial at the bottom. "N/A" denotes not applicable for this Pt. "A" denotes Pt is absent from the ward
  • EDD (Estimated date of discharge)
  • There is then a table under Pt safety handover checklist, Acute changes in Pt status = Medical review. There are repeats of various groups of vertical columns, including a date __/__/___, ND (not done), AM (morning), PM (afternoon). For this table, there are rows in accordance with:
    • Introduction:
      • Correct ID band on Pt (red if medication allergy)
    • Situation/background:
      • Immediate or parental concerns/care escalated. YES/NO
    • Assessment:
      • Vital signs are condition/age appropriate
      • Medication administred as prescribed, documentation completed
      • IV site access free from redness/inflammation
      • IV fluids administered according to orders using a burette and infusion pump and documented hourly
      • Input/Output Fluid Balance Chart completed
      • Weight recorded
      • Wounds, drains, rashes identified
      • Mobility/safety/falls risk checked
      • Infection control signage correct
      • Oxygen and suction equipment functioning
      • Equipment monitor alarms audible with appropriate parameters set
      • Pain assessment recorded
      • Pt/Carer in attendance
    • Recommendations:
      • Discharge education/information
      • Initials: Nurse/midwife handing over care
      • Initials: Nurse/midwife accepting care
Referral

Paperwork for "Referral/consultation medical record copy" includes:

  • Affix Pt label
  • Referring Dr, including Provider number, Pt status (circle) Public/Private
  • Attending specialist (AMO)
  • Referred to: ___ (name) of ___ (dept) (complete both)
  • Date, and Signature
  • Consult team contacted? Tick box. & Date, and Time
  • Reason for consultation
  • Provisional Dx
  • Summary of clinical condition
  • Object of consultation, including tick boxes for Advise on Mx, Share Mx, Take over care of Pt
  • Consultant's report, with note to (Use Clinical notes if more space is needed)
  • As requested I shall, tick box for Advise on Mx, Share Mx, Take over care of Pt
  • Authentication, including Date, and Signature
  • Billable Pts only (To be completed by Medical Officer undertaking consultation), with Date Seen, Item, AMO initial, which is repeated 3x horizontally
  • The white copy is the Medical record copy, which is CC'ed on the yellow Consultant's copy, and the green Billy services copy
Discharge

Discharge summary is a document ensuring continuity of care between hospital and community. D/C is shorthand for discharge. The Paperwork for the Discharge summary includes:

  • Affix Pt label
  • Admission date, and Discharge date
  • VMO (Visiting medical officer) and LMO (Local medical officer)
  • Final Dx
  • Operations
  • Complications
  • Presenting problem
  • Tx as an inpatient, including relevant Ix
  • Pneumococcal vaccination indicated: Yes/No
  • Follow-up services arranged
  • Ix not to hand at discharge
  • Drug allergies or reactions (new or existing)
  • Estimated time of discharge
  • Table of drugs, including Drug name, Strength, nstructions, Qty, Notes
  • Authentication, including Signature, Name (print), and Date, or Medical Officer, and Pharmacist
  • There are 3 copies of the sheet (2 CC's), the White going to Clinical Information Serices, Pink to LMO, Yellow to Pharmacy, Blue to VMO

The Paperwork for "Discharge Against Medical Advice" includes:

  • Affix Pt label
  • There are 3 alternate portions which can be filled out
  • Discharge of self, which is This is to certify that I, ___ am leaving ___ Hospital at my own insistence and against the advice of the attending Medical Staff. I acknowledge that I have been informed of the risks involved and possible consequences of my decision, including but, not limited to ________. I hereby release the Medical Staff and ___ Health Service from any responsibility and liability for any ill effects which may result from my leaving the Hospital at this time. This is followed by a Signed, Date, and Time. I certify taht I have Assessed the Pt as being physically and mentally capable of making a decision regarding discharge against advice; Counselled the Pt as to the possible consequences of self-discharge as listed above. And place for DOCTOR (print name), and DOCTOR (sign)
  • Discharge by self - refusal to sign, which is This is to certify that ___ (Pt name) was given advice as listed above, but refused to acknolwedge the same. ___ (Pt name) refused to sign this document. And place for Staff Name, Date, and Time
  • Discharge by guardian, which is This is to certify that I, ___ being the guardian of ___ am remmoving him/her from __ HOspital at my own insistence and against the advice of the attending Medical Staff. I acknowledge that I have been informed of the risks involved and possible consequences of my decision, including but limited to ___. I hereby release the Medical Staff and ___ Health Service from any responsibility and liability from any ill effects which may result from leaving the hospital at this time. Places for Signed, Relationship, Date, Time. I certify that I have Counselled the guardian as to the possible consequences of discharge as listed above. DOCTOR (print name), and DOCTOR (sign)
See also
  • Obs chart

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