Documentation And Reporting

As a nursing assistant, you represent a connection between your clients and other health care professionals. So, a major part of your job is to report and document or record all the relevant information that‚It’s related to the clients under your care. Medical records are subdivided into several sections that contain specific forms, including admission record, medical history, nursing history, physician‚It’s order sheet, medication administration record, physician‚It’s progress notes, narrative nurse‚It’s notes, graphic sheet, and miscellaneous documents. All medical records are legal documents except the Kardex card which is a condensed version of the medical record.