What are the contents of a Patient's chart? Nurses most used parts?

[newbiekenobe]

Hello, can you tell me the sections of a patients chart?

And then the parts nurses would have to deal with? Why?

Thank you expert nurses i'm newbiekenobe

[ChristineN, BSN, RN]

I find myself using the majority of the chart. There is:

orders

progress notes (from dr's, rn's, pt/ot, nutrition, and any other multidisciplinary team involved)

graphics (I&O, vital signs, labs)

MAR, meds

H&P, I tend to glance over this if it is my first time with the pt

Records from outside facilities, well I don't use this part of the chart much

Consults, where notes from other md's that are writing their initial consulting recommendations to the primary team would go

Oh and

Discharge paperwork, always important

[jammin246RN]

You almost forgot....Nurses Notes!

[GHGoonette, BSN, RN]

I can't really answer your question, because I only use those charts that deal with OR, PACU, fluid balance and medication.

As for my most-used parts, I'm not telling you.....

[ImThatGuy, BSN, RN]

You'll probably "use" the nurse's notes and medication record most. However, the first thing I look at are the physician's H&P and admitting diagnoses with labs and radiology reports being second in the case of already hospitalized patients.

[MckinleyRN]

The face sheet....You need it for everything......