Category | Examples |
---|---|
Progress notes | There are multiple types of progress notes, but 3 most commonly used at RFBI are: 1. User-entered notes recorded by nurses or caretakers 2. Automated notes generated after charts or assessments 3. Medication note when PRN (pro re nata meaning “as needed”) is administered |
Observation Charts | Most frequently recorded observation charts include: 1. Medication 2. Bowel Chart 3. ADL Chart 4. Blood Glucose Chart 5. Blood Pressure Chart 6. Weight Chart 7. Food Intake Chart 8. Fluid Intake Chart 9. Vital Signs Chart 10. Fluid Output Chart 11. Urinary Chart 12. Pain Chart 13. Behaviour Chart 14. Wound Chart 15. Neurological Observation Chart |
Assessments | Most frequently recorded assessments include: 1. Accident/Incident Report 2. Behaviour Assessment 3. Blood Glucose Monitoring Chart 4. Physical Assessment 5. Mobility Assessment 6. Medical History 7. Medication Incident Report 8. Infection Report 9. Meals, Drinks and Nutrition Assessment 10. Wound Assessment 11. Physio-OT (Occupational Therapy) Assessment 12. Daily Fluid Balance Chart 13. Skin Integrity Assessment 14. Wound Dressing Chart 15. Falls Risk Assessment Tool (FRAT) 16. Pain Assessment 17. Personal Hygiene Assessment |