Medical Services: Nursing Records and Reports
Abstract
1) Documentation of daily patient acuity classification on DA Form 4677 (Clinical Record--Therapeutic Documentation Care Plan (Non-Medication)) (chap 2) 2) Documentation of the nursing discharge summary, DA Form 3888-3 (Medical Record--Nursing Discharge Summary) (chap 2) 3) Use of DA Form 3950 (Flowsheet For Vital Signs and Other Parameters) (chap 3) 4) Documentation of the patient care nursing process during the preoperative, intraoperative, and postoperative phases--DA Form 5179 (Medical Record-- Preoperative/Postoperative Nursing Document) and DA Form 5179-1 (Medical Record--Intraoperative Document) (chap S) 5) Directions for Workload Management System for Nursing reports (chap 6) 6) Guidelines for the internal use of DA Form 3761 (RCS MED 371) (chap 6) This revision deletes the-- 7) Use of DA Form 4112 (Army Health Nursing Program--School Health Record) . (DA Form 4112 was rescinded by DA Circular 310-81-7, 15 Jul 81.) 8) Nursing audit; appropriate elements of the process are now incorporated in AR 40-68, appendix C. 9) Quarterly Narrative Summary Report for Clinical Nurse Specialists. 10) Use of DA Form 3888-1 (Medical Record--Nursing Assessment and Care Plan (Continuation)) This revision changes the-- 11) Documentation process and forms for the nursing history assessment and care plan--DA Form 3888 (Medical Record-- Nursing History and Assessment) and DA Form 3888-2 (Medical Record--Nursing Care Plan) (chap 2) 12) Content of Nursing Activities Report, DA Form 4798-R (Nursing Activities Report, RCS MED-369) (chap 6) 13) Submission of the quarterly nurse 5 activities report to a monthly report--DA Form 4800-r (Nurse Practitioner/Clinical Nurse Specialist Monthly Activities Report, RCS MED-370) (chap 6) 14) Administrative data throughout.
Document Details
- Document Type
- Technical Report
- Publication Date
- Aug 15, 1991
- Accession Number
- ADA403260
Entities
Organizations
- United States Army