patient chart pdf

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CLAY-PLATTE FAMILY MEDICINE CLINIC, PC PATIENT INFORMATION FORM Partnering for Excellence in Health Care Date Name First M.I. Last Address Apt. City State Zip Home Phone Cell Phone E-mail SSN Date
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Hey everyone its Sal with registered nurse orange calm and in this video we're going to go over how to master a patient chart now as a nursing student or a new nurse the very first time you are ever exposed to a patient's chart you're going to think oh wow how am I ever going to master this material because charts contain a lot of information about a patient and whenever you're new you don't know what's important compared to this you don't know what you need to know to help you do your job so in this video I want to help you with those things I want to talk about what's the most important information in a chart I'm also going to talk about ways that you can master it help you to get organized and to learn how to filter out is this important is this not important should I look here should I look there and how to actually organize all this information for reference okay first let's talk about Charney charts like I said contain lots of information I remember whenever I was a nursing student and we had to go to clinicals to do a care plan on a patient in order to do a care plan you have to look through a chart and I remember looking through the chart and this was before charting was online online Torian has made things a lot easier which I'll go into here in a second but the chart was just in a notebook and I remember thinking how in the world am I going to know what to look for to develop my care plan and whenever I become a nurse how am I going to be able to pick out the most important information to provide care to this patient but it does come to you and in this video I want to give you some tips on how to do that okay first let's talk about charting every system at a hospital is set up differently every prospero is going to use a different program they're going to call things differently so the key is you want to get familiar with the place that you're working with what type of stuff they use because one place I work they had online charting most of it was online but some of it was still in a paper chart so you want to make sure that you're familiarize yourself with that now online charting is great because one thing that I love about it is that I can look at patient's previous previous hospital stays and if they were there five years ago I can see why they were there if they had a heart cath what their heart cath showed everything like that and before then it was just in this paper chart and you would have to like call medical records and there would be a delay and it really hindered patient care so online charting is absolutely awesome so first let's go over how to organize this okay very first thing that i really recommend whenever you were a nursing student or new nurse is that you get or you make your own report sheet template and let me show you a sample one on my website register nurse RN comm a link should pop up you can go and download some free report sheets and right here I have some report sheet templates you could double side print...