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.
[Illustration: Patient’s Chart. Cardboard, five by eight inches]
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.