When you’re new to nursing, there are so many important details to keep track of, including patient charts, also known as electronic health records. Get some advice on what information is vital to maintaining patient records up-to-date while on the job.
Navigating the electronic health record (EHR), commonly known as the “chart,” can be challenging as you begin your nursing school and clinical journey. Once you log in, you may feel overwhelmed with the endless amount of information and tabs to access. You might find yourself asking, “Where do I even begin?” Don’t worry; this is normal and happens to everyone. So, let’s review six sections of the EHR that you can start with when researching your client for clinical.
1. Client Demographics
Client demographic information is a simple place to begin your exploration of the EHR. This section typically includes the client’s name, date of birth and may also contain important details such as isolation status, code status, admission date, and allergies.
2. Admission Progress Note
After reviewing the client’s demographics, you should access the client’s admission note which is usually written by a healthcare provider, like a doctor or nurse practitioner. This progress note gives a detailed description of why the client came to the hospital and comprehensive data regarding their first physical assessment, past medical history, family history, and social history. Keep your eye on the prize – this note may answer the question of “what will get your patient discharged?” by looking at the healthcare provider’s plan for the rest of the hospital stay.
3. Test Result Impressions
Depending on the healthcare provider’s orders, clients usually have blood (lab) work and diagnostic testing scheduled consistently throughout their hospital stay. Sometimes viewing these test results can be overwhelming and time-consuming; therefore, focus your investigation on the impression of these results. Usually, each test result contains a concise summary impression written by the clinician interpreting the findings, which can serve as a tool to understand more about your client’s condition. One thing most charts have is a way to examine data trends over time; then, you can see if a client’s Red Blood Cell (RBC) count is going up or continuing to fall.
4. Medication Administration Record
The Medication administration record (MAR) is another important aspect of the chart, which gives you information about the client’s past, current, and future medications. Although you might not be administering medications right away, the MAR can tell you details about medications that impact your client’s assessment findings and vital signs. If you have any questions, call the pharmacy – a pharmacist can be your best friend with medication questions.
5. Nursing Assessment Notes
Nurses typically write assessment notes on every client once per shift, which means your assigned client can have dozens of nursing notes to view. To better understand your client’s situation, read the last few days or shifts’ worth of nursing notes to compare baseline assessment and vital sign data to your current findings.
6. Health Care Maintenance (HCM)
While your patient is in the hospital, make sure their HCM is up-to-date. Often what they need is available while they are inpatient- like vaccines.
Remember everything you learn from a chart should be validated – often by the patient themselves – and it should give you insights on providing the best care. Make sure the provider’s goals are in alignment with the patient’s goals.
Contributors
Paige Randall MS, RN, CEN, CNE, Script Writer and Editor
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