USE OF NURSING KARDEX RECORDING

USE OF NURSING KARDEX RECORDING

PURPOSE OF NURSING KARDEX

1. To serve as a record of medical and nursing orders currently in effect for each patient in the ward cared for by the students of the college of nursing.

MAINTENANCE OF NURSING KARDEX:

1. A Kardex from will be maintained for all patients cared for by the college of nursing students. It will be filled out when a patient is first assigned to a student.
2. It will be checked and revised as needed, before giving care and daily after doctors rounds.

-          Ink will be used for all recordings except the following.

a)      Pencil is used for the recording of.

-          Bed no.

-          Diagnosis

-          Bath type

-          T.P.R & B.P. frequency and method

-          Diet

-          Nursing care plan

-          Treatments

b)      Red ink will be used to indicate the time of administration of medications from 7 p.m. to 7 a.m. Black ink will be used to indicate the time of administration of orders 7 a.m. to 7 p.m.

3. Only standard abbreviations will be used in writing orders on the Kardex. Do not abbreviate the name of the medications.
4. Drawing a red line through the order and writing the date and the initials of person canceling the order above the line will do cancellation of the orders.
5. The medication order should not be rubbed or over written.

METHOD OF FILLING IN KARDEX CARD:

I.                   Identification Data:

-          Use capital letters to record.

-          Name – copy accurately and completely from the admission record

-          Diagnosis – Record provisional diagnosis.

-          Any change in the working diagnosis.

-          Surgical procedure done with date.

II.                Medication:

a)      Write date, form and the name of the medication, frequency of administration in 24 hours, route of administration if other than oral and specific instructions concerning administration in column marked “medication”.

b)      In column marked “Dosage” Write the amount to be administered at the time of each administration.

c)      In the column marked “time” write the hours of administration.

d)     Stat, P.R.N. and S.O.S. medication orders should not be recorded in the Kardex card but the medicine card should be prepared and should be inserted in the Kardex.

e)      Alternate day, weekly and bi weekly medications with the pencil the due dates for three consecutive dosages.

III.             Treatments:

a)      In the column marked “treatment” write the date and name of the treatment, Example I/V, irrigation, diet, therapy, external applications, baking, frequency in 24 hours. And if applicable site, duration, temperature or strength of solutions and any special instructions.

IV.             Nursing Care Plan

a)      Write order relating to needed nursing care plan of the patient such as Hygienic care:

Special Mouth care

-          Shampoo

-          Posture and position – Frequency in 24 hours

-          Activity, rest and exercise.

-          Control of pain

-          Needs for health teaching or nursing care following discharge.

-          Needs for support in relation to emotions or mental attitudes.

-          Food or Fluid – Intake

-          Type

-          Amount

-          Frequency

-          Elimination

-          Use of comfort devices and safety  measures.

-          Recreation and diversion.

-          Plan to meet the spiritual needs

-          In the “time” column indicate the specific hours for carrying out nursing care if applicable.

-          Bath – Record if bed bath or shower, frequency and if not daily the specific days of week the bath is to be given.

-          T.P.R. – Record the method of taking if other than oral.

-          Diet – Record the type of diet ordered, supplementary feedings, if ordered. Limitation of food or fluid if applicable.

-          Health education of;

-          Disease

-          General

-          Family Planning

-          Prevention of disease etc.,