DOCUMANTATION Flashcards
(12 cards)
What are casenotes?
Casenotes are records created during a patient’s contact with medical staff, including histories, test results, and treatment records.
Casenotes include interactions with nurses, physiotherapists, and other healthcare providers.
What is the purpose of patient casenotes?
To document a patient’s medical history, treatment, and interactions with healthcare providers over time.
This builds a complete medical history essential for continuity of care.
What is a unitary file system?
A filing system where a single file is created for each patient, containing all relevant documents and history.
This system ensures continuity and easy access to patient information.
What are the essential components of a patient file cover?
- Patient’s name
- Patient’s number
- Year of last attendance
- Patient’s sex
- Any other critical information
The hospital name and ‘Confidential’ may also be printed on the cover.
What is the recommended type of fastener for casenotes?
Inert plastic fasteners are recommended to avoid physical damage to the documents.
Metal clips or staples can cause damage.
What are the different methods of documenting health records?
- Alphabetical
- Numerical
- Geographical
- Chronological
- Annual and date of birth
- Alpha-numerical
These methods help in organizing patient files systematically.
What is the purpose of closing casenote files?
To manage files that become too thick and to maintain organization by opening continuation files.
A file should be closed if it exceeds 3 cm (1 in) in thickness.
What should be included when marking a closed casenote file?
The wording ‘PART 1, CLOSED ON [DATE]’ should be used.
Current data must be copied to the new file cover.
What is an alphabetical numbering scheme?
A system using letters to categorize files, avoiding letters that can be confused with numbers (I, O, S, Z).
Examples include AAAA, AABB, CCCDE.
What is the numerical numbering scheme in health records?
A system that uses running numbers, such as 00001 to 99999, for patient casenote files.
This method helps in easily tracking patient files.
What is a chronological numbering system?
A method that organizes files based on the dates they were created or modified, using formats like YYYYMMDD.
This facilitates easy identification and sorting of files.
Fill in the blank: The hospital should have a _______ for each patient to ensure treatment coordination.
single file
This allows for a complete record of the patient’s history.
