Nurses perform a variety of tasks in the course of a day, from taking vital signs to performing emergency surgeries. While there is some variability from hospital to hospital, most nurses will have to perform some form of documentation throughout their career. There are several different types of documentation that nurses are required to maintain, including patient charts, incident reports, and progress notes. These records are very useful to both the nurses themselves and the organisation as a whole. In this article, we will explore some of the standard types of documentation that nurses are required to produce and maintain.
A patient chart is perhaps the most basic and fundamental type of documentation that nurses are required to produce. These records are usually kept in numerical order and are used to track the patients’ progress throughout their stay at the hospital. A patient’s chart may include personal information, such as age, weight, height, and whether or not they are pregnant or have children. It should also contain sufficient information about the patient’s condition, including presenting complaints, past medical history, vital signs, examination results, and relevant medical records. The minimum number of pages for a patient chart is eight.
An incident report is usually a form that is completed after a patient or resident has been involved in an incident that could have either harmed someone or caused financial loss. Common incidents that may require an incident report include falls, medication errors, and infections. These reports are usually a formal record of the incident and contain sufficient information about the patient’s condition at the time the incident occurred. The incident report form should be signed by the reporting nurse and include details about the patient, the incident, and the actions taken as a result of the report. The minimum number of pages for an incident report is 16.
A progress note is usually the type of documentation that is written after the patient has been discharged but is still under the care of the hospital. These records are similar to the patient charts in that they are used to track a patient’s progress after their initial hospital stay. The difference is that the progress notes will contain more information about the patient’s condition than the patient chart and will often be used to follow up with the patient after they have left the institution. Progress notes are also more commonly used to communicate with the patient’s primary care physician about the patient’s condition or to document any changes that have occurred as a result of treatment. The minimum number of pages for a progress note is four.
The above are the types of documentation that nurses are most commonly required to produce and maintain. While these forms are somewhat standard throughout the country, the contents of the forms and the number of pages required varies from state to state and hospital to hospital. Some of the information contained in these forms is optional and up to the individual nurses to decide what should and should not be included. It is always advisable to ask your local hospital or medical office for any requirements that they may have regarding documentation and to find out what types of forms they use so that you can be sure to order these forms from the institution’s supply house.