What goes inside a patients or residents medical chart

[mcclot1993]

I know that's where the nurses does their charting like the nurse charts their meds on the MAR. What information goes inside a persons chart

[RNsRWe, ASN, RN]

Why are you asking? Are you a pre-nursing student getting his/her bearings? I see from other postings you are a CNA....what is it specifically you are looking for?

[kiszi, RN]

Pt charts can be electronic, on paper, or (most often) a combination of both. There will be various sections for physician orders, lab results, consult notes, radiology reports, history & physical (completed by the MD), DNR forms, um, physical therapy notes, etc. etc. etc.

[TheCommuter, BSN, RN]

At my workplace, charts have been electronic since last year.

Charts typically contain the patient's name, address, phone number, next of kin information, insurance information, religion, race, and physician's name on a face sheet. Other chart info may include:

1. History and physical

2. Medication administration record

3. Laboratory reports

4. Radiology / ultrasound / Ct Scan reports

5. Dietary consult

6. Nurses Notes

7. Case management notes

9. Therapy notes (PT/OT/ST)

10. A list of physician's orders

11. Assessments (Braden, Fall risk, FIM, admission assessment, focused assessments)

12. Flowsheets with vitals, blood sugars and weights

13. Consent forms

14. Care plans

15. Respiratory therapy notes

16. Specialist physician consult notes

17. DNR forms

18. Advance directives

19. Physician's progress notes

And so much more. . .

[jschut, BSN, RN]

TheCommuter is right. There is so much information about the patient in the chart. When I worked and had a few minutes down time, I liked to read up on the folks I was taking care of... to give me a glimpse of "who" they were and "why" they ere. I think with everything listed, from their H&P to current diagnoses, to social service assessments, the information gave me a better idea of who my patient was as a whole... and I believe, helped me give better care.

[RNsRWe, ASN, RN]

Still curious as to the reason for the question out of the blue.....what's going on?

[Esme12, ASN, BSN, RN]

They are a CNA that is very interested in becoming a nurse.

mcclot....we have had this discussion before...you are putting the cart WAY before the horse. Commuter gave you a ton of valuable information. You need to focus on getting into nursing school. Learning all of this ahead of time will only confuse you later.