Record the drug round and the fluid chart
Record each drug given, held or refused on an admitted patient, and the fluids that go in and come out.
- Where
- Practice portal
- Who can do this
- Administrator, Doctor, Midwife and Staff
The ward chart is kept at the practice, so recording needs a connection. It is on the visit of a patient who is admitted.
Steps
To record a drug:
- Open the admitted patient's visit and choose Ward chart.
- Under Drug round, pick the Prescribed drug, or type the drug and its dose if it was not prescribed on this stay.
- Choose what happened: Given, Held, Refused or Not available. If it was not given, say why.
- Choose Record it.
To record fluids:
- Under Fluid chart, choose Went in or Came out.
- Type what it was, such as saline or urine, and the millilitres.
- Choose Record it.
What to expect
Each entry shows the time, what was recorded and who recorded it, newest first. The fluid chart adds up what went in, what came out and the balance. An entry is never edited: if one was wrong, record the right one beside it. Once the patient is discharged the chart can be read and nothing more is added.