Skip to main content

Table 1 Data recorded by RFBI aged care home

From: Development and validation of retrospective electronic frailty index using operational data of aged care homes

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