HOSPITAL FORMS 4. Recognize that the patient record is permanent.

Follow agency policy pertaining to the color of

v A medical or hospital forms are useful tool
ink and the type of pen to be used. Ensure that
utilized by medical facilities nowadays. This is the patient record is complete before sending it
done because of the benefits that the medical
to medical records.
forms can provide to the medical practitioners of
that institution.
IMPORTANCE OF MEDICAL RECORD COMMON HOSPITAL FORMS
v Medical records form an important part of a CONSENT FORMS
patient management. It is important for the
v Patient authorization for different treatments.
doctor and medical establishment to properly
maintain the records of the patient for 2 v As a general rule, if the patient is of
important reasons: consenting age, no treatment or procedure
should be performed without the patient’s
1. It helps in proper evaluation of the patient and consent.
to plan treatment protocol.
v Before carrying out an operation, treatment,
2. The legal system relies mainly on or procedure, doctors should obtain the
documentary evidence in cases of medical consent of the patient.
negligence. Therefore, medical records should
1. AUTHORIZATION FOR BLOOD
be properly written and preserved to serve the
TRANSFUSION
interest of doctor and nurses as well as his/her
patient. v This consent provides a structure for a
patient to make an informed choice regarding
the indications, risk, possible alternatives
PURPOSE OF MAINTAINING MEDICAL and benefits of a blood transfusion
RECORDS
1. Monitoring of the actual patient
2. Medical research
3. Medical/dental or paramedical education
4. For insurance cases, personal injury suits,
workmen’s compensation case, criminal cases,
and will cases
5. For malpractice suits
6. For medical audit and statistical studies

IMPORTANT CONSIDERATIONS
1. Sign your first initial, last name, and title to each
entry.
2. Do not use dittos, erasures, or correcting fluids.
a. Note: A single line should be drawn
through any incorrect entry and
words, and write “error” or
“mistaken” above them. Then
2. PROCEDURAL AUTHORIZATION
the entry should be rewritten
correctly. v Consent for Diagnostic/ Treatment/
3. Identify each page of the record with the Surgery (Minor, Major)
patient's name and identification number.
v Consent For Anesthesia Administration
3. AUTHORIZATION FOR ADMISSION AND 5. ADMISSION RECORD
HOSPITAL TREATMENT
v Information on patient identification,
conditions for admission, and consent for
general medical and nursing care

4. DO NOT RESUSCITATE (DNR) FORM

v A DNR form is an end-of-life medical directive
that instructs health care professionals to
withhold life-sustaining treatment at the 6. PATIENT HISTORY AND PHYSICAL
behest of the patient. EXAMINATION FORM
v Physicians record of the patient’s medical
history and findings of the current physical
examination.
 ü List of medications
ü List of IVF
ü List of daily treatments & procedures
ü List of Diagnostic procedures
ü Allergies
ü Specific data on how the client’s
physical need is to be met
ü A problem list, stated goals & list of
nursing approaches to meet the goals

7. PHYSICIAN'S ORDERS
v Also known as Doctor’s order sheet.
v The physician’s directives for patient care.

9. NURSE'S NOTES
v Written report of the nursing process
consisting of the Focus, Data, Action and
Response (FDAR) of the patient’s current
condition.
v Record of intervention implemented and the
patient’s response to them.

8. KARDEX
v Widely used, concise method of organizing
& recording data about a client, making
information quickly accessible to all health
professionals.
v It is kept in a portable index file folder
v It should always be updated
v Contents:
ü Pertinent information about the client
IMPORTANT CONSIDERATION IN Note: Black ink: Body Temperature
DOCUMENTING NURSES NOTES:
Blue Ink: Respiratory Rate
v Check to make sure you have the correct chart
before writing. Red Ink: Heart Rate

v Chart on the proper form as designated by

agency.
v Print or write legibly in dark ink or as per agency
protocol.
v Use correct grammar, spelling. Use standard
terminology, terms, abbreviations, and symbols.
v Date and time of each entry.
v Chart nursing interventions chronologically on
consecutive lines. Never skip lines. Draw a
single line through blank spaces.

10. PRE-OPERATIVE/ PRE-ANESTHESIA

CHECKLIST
v List used to verify that the patient is ready
to undergo surgery. 12. FLUID INTAKE AND OUTPUT RECORD
vSerial record of 24-hour intake and output.
vRecord of all Intake of patient: oral, parenteral
and tube gavage.
vRecord of all output of patient: urine , emesis/
lavage and tube drains.

11. GRAPHIC CLINICAL RECORD

v Also known as TPR sheet
v Record of serial measurements and
observations, such as temperature, pulse,
respiration, blood pressure, weight and diet.
13. VITAL SIGNS AND BLOOD GLUCOSE 15. MEDICATION ADMINISTRATION RECORD
MONITORING RECORD
v also known as Medication Sheet
v Vital signs are measured to obtain basic
indicators of a patient’s health condition. v Documentation of all medications ordered,
v Blood glucose monitoring is to protect dosage, route, frequency and doses not
taken by the patient.
persons who may have or who are having
problems caused by an abnormal blood
glucose condition.

14. NEUROLOGICAL VITAL SIGNS(NVS)

RECORD
v A nursing assessment of the patient’s
neurological status incorporates monitoring
of the patient’s level of consciousness, pupil
reaction and motor function, as well as
observation of vital sings.

16. PARENTERAL FLUID RECORD

vAlso known as Intravenous (IV) Flow sheet.
vRecord of IV fluids including the:
ü Date& time started/ ended
ü IV site
ü Type of parenteral fluid & stock volume
 ü Incorporated drugs 18. DISCHARGE INSTRUCTION FORM
ü Flow rate
v Information about instructions given
ü name & initials of the nod who regarding:
started/ended
ü Home medications
ü Diet
ü Activities (household duties and
exercise)
ü Other instructions such as wound
care and signs and symptoms to
report to the physician.
ü Also includes when to next see the
physician (venue & date/time)

17. CLINICAL LABORATORY / ECG REPORT

v results of different laboratory tests and ECG
results are attached.
POSTPARTUM EXERCISES v Drink plenty of fluids.
v Wear a supportive bra and wear nursing
u POSTPARTUM means the time after childbirth. pads if breastfeeding mother.
u POSTPARTUM PERIOD v Stop exercising if you feel pain.

- Begins immediately after childbirth as the

1. ABDOMINAL BREATHING
mother’s body, including hormone levels and uterus
size, return to a non-pregnant state. v Assume a supine position with knees bent.
Inhale through the nose, keep the rib cage as
-It also refers to the first six weeks following stationary as possible, and allow the
birth. abdomen to expand.
u EXERCISE v Then contract the abdominal muscles while
exhaling slowly through the mouth.
-Is an activity that requires physical effort. It v Instruct her to place one hand on the chest
is carried out to sustain or to improve health and and one hand on the abdomen while
fitness. inhaling.
v The hand on the abdomen should rise and
u POSTPARTUM EXERCISES the hand on the chest should remain
stationary.
- A series of physical exercise that are
performed by the postnatal mothers to bring about
optimal functioning of all system, prevent
complications and an important part of their
recovery.
u BENEFITS OF POSTPARTUM EXERCISES
v Help restore and improve muscle strength
and firm up body.
v It raises the energy level and improves sense
of wellbeing.
v Promote postnatal weight loss.
(Recommended 1kg per week)
v Improve cardiovascular fitness.
v Improves bladder control and less urinary
incontinence
v Prevent separation and weakness of the
abdominal muscles 2. HEAD LIFT
v Prevents aches and pain v Assume a supine position with knees bent
v Improve the mood, relieve stress and help and arms out-stretched at the side.
prevent postpartum depression. v Inhale deeply to begin then exhale while
v Improves quality and quantity of sleep. lifting the head slowly.
v Hold position for a few second then relax.
NOTE: It is important to consult a healthcare
provider for medical clearance before exercise,
especially if a mother had a c-section or experienced
a complication during pregnancy or birth.

u GUIDELINES WHEN PERFORMING

POSTPARTUM EXERCISE
v Take time to warm up and cool down.
v Begin slowly and increase pace gradually.
3. MODIFIED SIT-UPS KEGELS EXERCISES
v Sit, stand or lie on your back with your knees
v Assume a supine position with arms
outstretched and knees bent. bent and legs comfortable apart
v Gently tighten and relax the muscles of
v Raise head and shoulders as hands reach for
perineum (pelvic floor muscles).
knees.
v Hold the contractions for ten seconds. Then
v Raise shoulders only as far as the back will
release slowly.
bend; waist remains on the floor.

4. KNEE AND LEG ROLLS

v Lie flat on the back with knees and feet flat on

the floor or bed.
v Keep shoulders and feet stationery and roll
knees to touch first one side of the bed then the
v Instruct mother to repeat each exercise up to
other.
five minutes twice a day, at first then
gradually increase as the mother gains
strength.
v
WARNING SIGNS: WHEN TO STOP
POSTPARTUM EXERCISE
v Increased fatigue
v Muscle aches and pain
5. CHEST EXERCISES v Changing color of lochia from pink to red
v Heavier lochia flow
v Lie flat with arms extended straight out to the v Lochia starts flowing again after it had stopped
side then bring the hands together above the
chest while keeping the arms straight.
v Hold for a few seconds and return to the starting
position
v Bend elbows, clasp hands together above
chest, and press hands together for a few
seconds.