RECORD OF INTENSIVE CARE UNIT

Introduction

• Every ICU keeps some kinds of records. The clinical record is a brief account of the personal and medical history of the patient, results of diagnostic test, findings of medical examination, treatment and nursing care, daily progress notes and advice on discharge.
• Documentation in the ICU is carried out for a number of reasons. It ensures continuity of care and provides up-to-date patient status. It fulfills hospital policies which furnish the legal aspects of 'duty of care'.
• The intensive care nurse has to be highly skilled today due to technological advances and complex care of the critically ill patients. Also the documentation and care required are complex and time consuming.

Principles of Record Writing

• Since the clinical record is a legal document, it is essential that they should be written clearly, accurately, appropriately and legibly.
• All entries should be signed by the individual who writes them.
• Care to be taken, not to make any errors on the records. If anything is crossed out, it should be dated and initialed.
• All records should be written with black ink or typed for better legibility.
• Records should be written in chronological order as to date and time. When recording medications and treatments, note exact time and date on which they are carried out.
• Records are written continuously with no blank spaces. If any space is left out, it should be crossed out, dated and signed.
• Lengthy corrections of records are written as amendments.
• Each page of the record should be properly identified with the name, age, I.P. No., O.P No., date etc.
• Use only standard abbreviations.
• Records should be truthful, brief and complete. It should include all the services given to the patients, the observations made on the patient from day to day and the results of treatment etc.

Types of ICU Records

Patient records

• Every ICU maintains complete patient record. This will contain the –
• Bio data of the patient,
• Diagnosis,
• Family history,
• History of the past and present illness,
• Signs and symptoms,
• Findings of medical examination & investigations,
• Treatments & medications,
• Progress notes and
• Summary made at the discharge of the patient

Nurse's note's

• Large parts of the patient's records are filled by the nurses.
• Nurse's notes are a record of treatments and nursing measures carried out by the nurses, their effects, the observations made on the patient. Avoid bulky reports containing unnecessary and irrelevant materials.
• Observation of the patient is continuous and it is impossible for the nurse to record all her observations. She should record what she thinks that might affect the diagnosis, medical treatment, nursing care and rehabilitation. Observation should be as specific and objective as possible.

Doctor's order sheet

• The doctor's orders (prescriptions) regarding the medication investigations, diet etc., may be written on separate sheets.

Graphic charts of T.P.R.

• On this the temperature, pulse and respirations are written in a graphic form so that a slight deviation from the normal can be noted at a glance.
• Other Information such as blood pressure, number of bowel movements, the body weight, name and date of operation, removal of sutures etc., may be recorded on this chart according to the hospital customs.

Intake and output chart.

• Patients on intravenous fluids or on the fluid diet, critically ill patients, post-operative patients, patients with oedema, patients having vomiting and diarrhoea, patients getting diuretics etc., should have their intake and output maintained.

Registers

• To maintain the statistics, every ICU maintain certain reg¬isters such as registers for the register for the admis¬sions and discharges,registers for operations, census register, register for the biopsy etc. It is the nurse's responsibility to maintain these registers up to date.

Others

• Reports of laboratory examinations- such as ECG collection, biochemistry, hematology
• Diet sheets
• Consent form for operations and anesthesia
• Reports of anesthesia, physiotherapy, occupational therapy, and other special treatments.
• Others used occasionally are:
• peritoneal dialysis chart
• Swan Ganz chart
• lung function chart

Value of Records

• Record provides an accurate and detailed account of treat¬ments and care given to the patient. Therefore it serves as a guide for follow up of the course of disease and future care.
• The record provides accurate information of the results of medication and treatments given to the patient. So, through the records the physician gets accurate information about the patient's conditions from day to day.
• Records are of great value in the diagnosis, treatments and nursing care.
• A record of illnes sand treatment saves duplication of work in the future care especially when the patient is transferred from one department to another or from one institution to another or when an attending physician is transferred and other person takes charge. In such situations it helps the patient to get prompt treatment.
• A well written record has a legal value. The records safeguard the patients, nurses, doctors and the hospital. It serves as evidence that the patient care is intelligently managed.
• Records are tools of communication among the members of the health team. It is of great value for the doctors and nurses at the shifting of duty hours.
• Records help the medical and nursing students in their clinical experience and provide data for care studies.
• Records serve as a reference material for research work.
• The patient's record, registers and reports furnish the vital statistics and give information needed to evaluate the services rendered by the hospital to the community.
• Data taken from the patient's record points out the health problems of the country and it also provides a base line In which local, state, national and international health services are planned.

Care of Records

• The records are kept under the safe custody of the nurse in each ward or department.
• No individual sheet is separated from the complete record.
• Records are kept in a place, not accessible to the patients and visitors.
• No stranger is ever permitted to read the records.
• Records are not handed over to the legal advisors without the written permission of the administration.
• All hospital personnel are legally and ethically obligated to keep in confidence all the information's provided in the records.
• All records are to be handled carefully. Careless handling can destroy the records.
• All records are filed according to the hospital custom, so that they can be traced easily. Records could be arranged :
  • Alphabetically.
  • Numerically.
  • With index cards.
  • Geographically.
• All records are identified with the bio data of the patients such as name, age, ward, bed no., O.P. no., I.P. no., diagnosis etc.
• Records are never sent out of the hospital without the doctor's permission. Reference is made by writing separate sheets and sending to the agency who requests for them e.g., reference letters, discharge summaries.