3.4.2 Understanding the Medical Record

Every client who receives medical care in Canada has a medical record which contains all information required to provide medical care to that client.  A medical record is the record, whether paper or electronic, of a client’s medical information, including care and procedures done for the client. When you are assisting with care provision in a facility, you will need to document the cares you perform.

Documentation is extremely important because it allows a care team to work together effectively to support a client. Documentation ensures that all members of the care team are aware of the same plan and are working together to complete it. You must take the time to learn how to understand client documentation, and how to write clear and effective documentation yourself.

In most cases, the medical record content includes all or most of the following types of documents. Please note that the names and purposes of some documents may vary according to your facility or agency.

1. Demographic sheet. This includes the client’s information, name, address, etc.
2. Medical history. The client’s diagnosis, or diagnoses, including results of a head-to-toe assessment completed by the physician.
3. Physician’s order sheet, also called a professional progress sheet. This page logs medication, diet, therapies, treatments and procedures, showing up-to-date medical course and progress. The physician’s progress note as well as other health care team members’ notes may be on one sheet.
4. Advanced directive / DNR (Do Not Resuscitate) orders. These orders are written after discussion with the physician and signed by the client and a nurse or physician. The orders state that the client’s physical status is within the guidelines which allow a client to make the decision that, should they suffer a cardiac arrest and they believe their life would not be of quality after Cardiopulmonary Resuscitation (CPR), they may chose to direct the medical staff not to resuscitate them. Please visit the Hospice Palliative Care Ontario website for more information on advanced directives.
5. Diagnostic procedures, labs, x-rays, surgeries, biopsies, and treatment sheets from providers.
6. Records of consultations with other physicians, specialists, and interdisciplinary health professionals (including therapists, dentist, podiatrist, Nurse Practitioner, spiritual advisors, advocates, etc.)
7. A nursing diagnosis form, which states the ways nurses determine care protocol  based on the symptoms a client exhibits.
8. A nursing care plan, which directs nursing care for the client’s physical and social care, containing specifics of each nursing care directive. 
9. Medication sheets to record daily medication administration.
10. Task sheets, daily care record. This record tracks vital signs (pulse, respiratory rate, temperature and blood pressure measurements), baths, all intake, bowel movements, etc.
11. Discharge plan.
12. Insurance or funder information.