LUCKNOW PUBLIC SCHOOL

SESSION
2023-2024
HEALTH CARE PROJECT
MAINTAINING RECORDS AND
DOCUMENTATION

SUBMITTED BY:
DIVYANSH SRIVASTAVA
XII-B
ROLL NO.:
 CERTIFICATE
THIS IS TO CERTIFY THAT DIVYANSH SRIVASTAVA
OF CLASS XII B HAS SUCCESSFULLY COMPLETED
THE PROJECT WORK UNDER MY SUPERVISION
FOR CLASS XII PRACTICAL EXAMINATION
CONDUCTED BY CENTRAL BOARD OF
SECONDARY EDUCATION IN THIS YEAR 2023-
2024.

IT IS FURTHER CERTIFIED THAT THIS PROJECT IS

THE INDIVIDUAL WORK OF THE CANDIDATE
AND UPTO AS PER MY EXPECTATIONS ISSUED BY
CBSE .

Mr. SANTOSH KUMAR SINGH Mrs.SURABHI SHARMA

( TEACHER) (PRINCIPAL)
 ACKNOWLEDGEMENT
I would like to express my deepest gratitude to my teacher,
Mr.Santosh kumar singh , for their exceptional guidance,
unwavering support, and extensive knowledge throughout the
completion of my class 12-B health care project. Their
enthusiasm for the subject and continuous assistance were
instrumental in shaping the success of this project.
I am immensely thankful to my parents and family for their
constant encouragement and belief in my abilities. Their
unwavering support provided me with the motivation and
determination to excel in this project.
I would also like to acknowledge the contributions of my
classmates who actively participated and shared their
observations and insights during the project’sdevelopment.
Their collaboration and exchange of ideas enriched the
project’s overall quality and contributed to a deeper
understanding of concepts.
Lastly, I extend my appreciation to the school administration for
providing the necessary facilities, and equipment required for
conducting experiments. Their support and commitment to
academic excellence have been crucial in the successful
completion of this health care project.
 MEDICAL RECORDS
The terms medical record, health record and medical chart are used
somewhat interchangeably to describe the systematic documentation of a
single patient's medical history and care across time within one particular
health care provider's jurisdiction. A medical record includes a variety of
types of "notes" entered over time by healthcare professionals, recording
observations and administration of drugs and therapies, orders for the
administration of drugs and therapies, test results, X-rays, reports, etc.
The maintenance of complete and accurate medical records is a
requirement of health care providers and is generally enforced as a
licensing or certification prerequisite.
The information contained in the medical record allows health care
providers to determine the patient's medical history and provide informed
care. The medical record serves as the central repository for planning
patient care and documenting communication among patient and health
care provider and professionals contributing to the patient's care. An
increasing purpose of the medical record is to ensure documentation of
compliance with institutional, professional or governmental regulation.
 MAINTAINING RECORDS
Documentation is a set of documents provided on paper or on digital
media. The procedure of documentation include drafting, formatting,
submitting, reviewing, approving, distributing, reporting, tracking, etc. the
purpose of complete and accurate documentation is to foster quality and
continuity of care. In this session, you will learn about different methods
of documentation and their formats. You will also study different types of
records. Relevant Knowledge Of The different methods of documentation
system are evolved to achieve specific aims. Familiarity with the different
systems will enable you to adapt the appropriate system in a particular
health care setting.
Source Oriented Medical Record- Source Oriented Medical Record is a
type of medical record kept according to health discipline e.g.,
medicine, nursing, laboratory, X-ray etc. These records include
information about care given, the patient’s response to care, and other
events documented chronologically and sequentially in a specific location
in the record designed for the particular health team member making the
entry.
The advantage is that the filing and retrieving of data is easy. It organizes
the information according to patient care department that provided the
care, or who provided the care. The main advantage of this format is that
the filing of reports is easy. Professionals would just have to look at where
the report came from and date, and file in that section. The main
disadvantage is that it would be difficult to follow a certain course of
treatment for the patient, since they would have to search through
everything, making it time consuming. Also if a facility has many different
departments, there will be even more sections in the record to search
through.
Problem Oriented Medical Records- There is an index list that defines
each problem. Everything is itemized and specific problems are organized
into four parts. The main advantage is that it makes it easier to follow a
course of treatment under a specific problem. However, this type would
be time consuming as well, especially to file a new problem in it. The
POMR consists of four components, the database, the problem list, initial
plan for each problem and progress note for each problem.
Documentation Format
There are a variety of documentation format utilized by the health care
provider. They include: 25 Session 4: Maintaining Record CBSE Study
Material - XII - 2019 33Sector: Healthcare
(i) Narrative charting: It is a free style method of documentation. It is
a method of charting that provides information in the form of
statements that describe event surrounding patient care. It is
often relatively unstructured and so provides flexibility in
determining how information is recorded or the format may be
structured and problem focused.
(ii) Problem focused charting: This includes the following:
A – Assessment
P - Problem identification
I – Intervention
E - Evaluation
The process begins with an admission assessment that is usually
completed on a separate form and the initiation of a problem list
that is based on the initial assessment. Documentation of patient
care is focused on intervention and evaluation related to
problems listed. Each entry in the progress note is preceded by
the date, time, and problems listed.
Maintenance of Records
1. The records are kept under the safe custody of the GDA in each
ward or department.
2. No individual sheet is separated from the complete record.
3. Records are kept in a place, not accessible to the patients
and visitors.
4. No stranger is ever permitted to read the records.
5. Records are not handed over to the legal advisors without the
written permission of the administration.
6. All hospital personnel are legally and ethically obligated to
keep in confidence all the information‟s provided in the records.
7. All records are to be handled carefully. Careless handling can
destroy the records.
8. All records are filed according to the hospital custom so that
they can be traced easily.
9. All records are identified with the bio-data of the patients such
as name, age, ward, bed no., diagnosis etc.
10. Records are never sent out of the hospital without the doctor‟s
permission
Types of Records
1. Outpatient and Inpatient Records – in most of the hospitals,
the inpatient recorded will be continuation of the outpatient
record. Outpatient record is continuation of the outpatient
department. This will contain the filled up in the outpatient
department. This will contain the biodata 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.
2. Doctor’s Order Sheet – The doctor‟s orders regarding the
medication investigations, diet etc. may be written on separate
sheets.
3. Graphic charts of T.P.R. – In this type of record, the
temperature, pulse and respiration are written in a graphic form
so that a slight deviation from the normal can be noted at a
glance.
4. Reports of Laboratory Examination
5. Diet Sheets
6. Consent form for Operation and Anesthesia
7. Intake and Output Chart – Patient‟s on intravenous fluids or on
the fluid diet, critically ill patient post – operative patients, patient
with oedema, patients having vomiting and diarrhea, patients
getting diuretics etc.
8. Reports of Anesthesia, Physiotherapy, Occupational Therapy
and other Special Treatment
9. Registers – To maintain the statistics, every hospital maintains
certain register, such as resisters for the births and deaths,
registers for operations and deliveries, census register, register
for the admission and discharge, register for the OPD attendants,
etc. Documentation of Medico-legal cases The important
 documents to be maintained by the hospital in Medico-legal
cases are as follows:
(i) Police intimation: This has to be given to the nearest police
station by the hospital.
(ii) Wound certificate: These are given on request by the police. It
must be duly signed by the medical officer, who has attended the
patient.
(iii) Discharge certificate – this is given on demand from the police
for MLC cases
Accident cum wound register: this is usually maintained by the
casualty medical officer. In case the patient demands, medical
certificate may have to be issued by the hospital.
Medication Record
This is a record which keeps track of medicines taken by the patient. It
includes date, time, route of drug, frequency and signature of GDA.
Nursing Discharge / Referral Summaries
This is made on discharge of a patient or at the time of transfer of a
patient to another health care institution.
Role of GDA in Maintaining the Records
The major role of GDA is to compile, process and maintain medical
records, which include information about the patient‟s care on the
following aspects:
• Baths
• Showers
• Oral care
•Denture care
• Foot care
• Hair and nail care
• Urinary catheter care
• Back care
• Turning and positioning
• Meal intake
• Fluid intake
• Activities, like walking
• Range of motion exercises
• Warm soaks
• Height
• Weight
• Urinary drainage bag output
• Temperature
• Pulse
• Respiration rate
• Blood pressure
• Blood glucose readings
COMPONENTS OF MEDICAL RECORD:-
RETRIEVE OF PATIENT
RECORD :
 CONCLUSION
Records management, also known as records and information
management, is an organizational function devoted to the
management of information in an organization throughout its life
cycle, from the time of creation or receipt to its eventual disposition.
This includes identifying, classifying, storing, securing, retrieving,
tracking and destroying or permanently preserving
records. The ISO 15489-1: 2001 standard ("ISO 15489-1:2001")
defines records management as "[the] field of management
responsible for the efficient and systematic control of the creation,
receipt, maintenance, use and disposition ofrecords, including the
processes for capturing and maintaining evidence of
and information about business activities and transactions in the form
ofrecords".
 BIBLOGRAPHY
In completion of this project, I have the help
of the following:
 Health care book
 https://en.wikipedia.org/wiki/ISO_15489
 Wikipedia
 Google