CHAPTER V
Records and Reports—The Patient’s Chart—Closing the Chart—The Card Index—Nurse’s Daily Report Sheet—Weekly and Monthly Reports—Examination of Charts.
Records and Reports. Every association, whether it be private or municipal, supporting one nurse or fifty, should keep careful records concerning its patients, and concerning its nurses’ work. These two sets of records should dovetail and form a cross file; by looking at the patient’s chart, one should be able to note the condition of each individual case, and how often and on what dates he was visited. By looking at the nurse’s record, one should be able to know exactly how she had employed every moment of her day, and to see the number of patients she had visited during the course of it. The patients’ charts account for the patients—the nurse’s daily report accounts for her work among them.
The Patient’s Chart. Each patient should have a chart made out for him at the moment when he is taken on the visiting list. This also applies to suspects, or those for whom the diagnosis is not positive, but whom the nurse is required to visit and care for. This also applies to those moribund patients, who may live but a few hours after being reported, and who die before a second visit can be made. Whether he has been on the list a year or an hour, it is necessary to account for every patient who passes under supervision, and to record the result in each case. Unless this is done, accurately and promptly, it will be impossible to estimate the amount of work, and its value to the community.
The patient’s chart should contain name, sex, age, colour, address, occupation, social status (married, single, or widowed), and a brief history concerning the onset and progress of his disease. These charts may be as simple or as elaborate as one desires. Herewith is submitted a specimen chart, such as are used in Baltimore; they are not perfect, nor the acme of all that is or might be desirable in a record of this kind, but they have proved simple and fairly satisfactory. There is much left out which with advantage might have been added, but in this connection it is well to remember that an elaborate and exhaustive history, one demanding dozens of intimate details, is apt to alarm the patient excessively. To collect exhaustive statistics would be valuable for the sociologist, but to do so at the expense of the patients’ confidence and trust would be to defeat the object of the work itself.
Patient’s Chart. Cardboard, five by eight inches
Reverse side of Patient’s Chart, showing spaces for recording visits. The Second Chart Sheets are similar to this, but alike on both sides
The reverse side of this chart contains spaces in which each visit may be recorded. Sometimes these charts are kept up for months and years, and it is therefore necessary to have what are called second sheets—alike on both sides, and resembling the reverse side of the first sheet, which contains the patient’s history. These sheets are fastened together, and the chart of a chronic case may thus record hundreds of visits. Each nurse is responsible for keeping up the charts of all patients under her supervision. The notes should be carefully recorded at the end of each day’s work, for it is bad policy to let this charting accumulate for even two or three days. The entries should be brief and concise, and should describe the patient’s condition, or the work done for him.
Each nurse should have a filing box or drawer in which to keep these charts; they should be arranged in alphabetical order, and kept at the central office, where the superintendent may have ready access to them. These charts are the property of the association, and under no circumstances are to be removed from the central office. The nurse may make her entries upon them either at the end of the day’s work, or before she goes on duty the next morning.
Closing the Chart. Patients are removed from the visiting list when they die, or when they are discharged. They are discharged only for one of three reasons—either they leave the city, or they move and their address is lost, or they prove not to be tuberculous. When a patient dies or is discharged, a suitable entry is made on his chart, which is then turned in to the superintendent of nurses, or to whomever is responsible for the records. If there is only one nurse, it is of course her duty to file these closed histories. These records should be rich mines of sociological information, and should contain valuable material for those who have access to them, such as municipal authorities, physicians, and social workers. Except for the access allowed to these, the files should be confidential.
The Card Index. All offices should contain a card index, giving the name and address of each patient under supervision. Change of address should always be noted, since it is only by means of this card index that the particular chart desired can be referred to. For example: the card index contains the names of some 3000 cases, all under supervision, and each one having its own chart. The charts themselves, however, are distributed among the filing boxes of several nurses. If particulars are wanted concerning John Doe, it would be necessary to turn first to the card index, find his address and the district in which he lives, and then turn to the filing box of that district and take out the chart. If it were not for the card index, it would be necessary to search through all the filing boxes before finding the desired chart.
Card, three by five inches, used in Card Index
As the discharged charts are handed in, the corresponding card in the index is withdrawn and filed away in a drawer containing either the dead or the discharged cases according to circumstances. This is a very simple way of keeping records, and of balancing from day to day the number of patients on the visiting list. This balance may be made every week or every month, as desired, for it is a simple method and reduces to a minimum the opportunities for mistakes in addition and subtraction. Needless to say, no one but the superintendent or her secretary should have access to, or touch these files in any way.
Nurse’s Daily Report Sheet. Beside the patients’ charts, the nurse must fill in a day sheet, or daily report of her work, to be handed to the superintendent, or to whomever she is responsible. This sheet accounts for her time and occupation all through the day. Beginning with the time she goes on duty in the morning, she will record each visit to each patient, the service rendered, and the time spent on him. She will also record the time she reached her office for lunch, and the time she left it for her afternoon rounds, also the hour at which she went off duty for the day. A record of this kind means additional clerical work, but how else is the nurse to account for her day? And be it noted, it is always a satisfaction to the nurse to place on record the summary of her day’s work.
Nurse’s Daily Report Sheet, seven by nine inches
This daily report sheet is of great value to the superintendent: without it, there is no way in which she can estimate either the quality or the quantity of each nurse’s work. A glance at the report will show whether the day has been light or heavy; it will show the number of new patients and ill patients, and how many bed-baths and dressings were given; how much time was spent in calling on doctors, dispensaries, social workers, and so forth, and arranging houses for fumigation. In short, a record of this kind shows the day’s work at a glance, and is the only way in which it can be satisfactorily accounted for, and if necessary verified.
Day Sheet, used for summarizing the day’s work. From this sheet the weekly and monthly reports are made out
True, this information may be obtained by going over the charts one by one, and verifying the records made upon them. But this is a clumsy and laborious way of doing it. If a nurse has two hundred charts in her box, and pays fifteen visits a day, it would be necessary to search through the whole boxful of charts in order to find the fifteen cases visited. A day sheet therefore, is not only a simple and practical way of recording a day’s work, but it is a protection both to the nurse and the work itself.
Weekly and Monthly Reports. From her daily report sheet, the nurse should make up a weekly or monthly report, to be turned in at specified intervals. This weekly or monthly balance sheet should be presented to the superintendent, or to the officers of the association to whom the nurse is responsible. Herewith is given a sample of the monthly report cards used in Baltimore, but again attention is called to the fact that these are not the last word in desirability. In using them as models, they would of course be altered to meet local needs or conditions, and enlarged or changed to suit other requirements. These monthly reports should be carefully filed away; they are needed for the construction of the annual report, and it may be necessary to refer to them on other occasions.
Card, four by six inches, used for summarizing the weekly and monthly reports
Examination of Charts. One of the duties of the superintendent is to examine the patients’ charts from time to time, to see how well the nurses do the clerical work, which is quite as important as the visiting itself. By carefully examining the charts, the superintendent is able to call the nurse’s attention to any lapses in them—incomplete histories, long intervals between visits, and so forth. If, for any reason, the nurse allows considerable time to elapse between her visits to a patient, the reasons for this should be fully noted on his chart. For example: some one wants to know when Mrs. Jones was last visited. On looking at the chart, we find the last visit was made on June first—and it is now August first. A two-months’ gap between visits looks like careless and inattentive work. The nurse, being questioned, however, is able to give a satisfactory explanation—Mrs. Jones had gone to pick berries, leaving the city the first of June, and not due to return till the first of September. This important fact, however, should have been noted on the chart, since it is almost as careless not to have made this entry, as it would have been to neglect the patient for so long a time. If a chart is to have any value, it should tell its own story, briefly and clearly.
These charts, therefore, should be examined every two or three weeks. It is the duty of the superintendent to go over these records, just as it is her duty to make rounds from time to time among the patients, and visit them in their homes. This is done by the superintendent, not in a spirit of distrust or suspicion, but because she is the person responsible for the work, and it is her duty to oversee it, and bring it to its highest degree of efficiency.