All registered Nurses know that medical records are legal documents. However, medical records are also used to communicate information, assess interventions, document care and treatments given, research, assess future needs and give directions.

A nursing assessment form is completed by the Registered Nurse who sees and assesses the patient when he is placed under her care by the triage nurse. In some instances the nurse receiving the patient can be an Enrolled Nurse or a LPN (licensed Practical Nurse - Canada and the USA). All relevant information is entered on the Nursing Assessment Form.

All Patient care documents created by the Doctor, Registered Nurses and all other Health Care professions must be concise and precise. Further they must be legible, comprehensive, objective, and timely. Important issues which involve other health care professionals must be expeditiously communicated to them. Please remember these points when doing assessed exercises. For how long do the medical records of a patient need to be stored in your State or Territory?

Why is the Nursing Assessment Form important?

  1. A properly completed Nursing Assessment Form documents the baseline condition of the patient upon arrival. It tracks the progress or lack of progress for the patient.
  2. Document treatments given or need to be given.
  3. Used as a communication tool to relay instructions for executing appropriate treatments.
  4. Used as a tool for monitoring the provision of service entitlements. It can also be used to monitor if specific services are had not been given.
  5. A Nursing assessment form can be used to assess future needs of the patient.

It is a Legal Document which insures that the patient has had a certain standard of care to which he/she is entitled.

Some things to remember in the Northern Territory!

  1. In the Northern Territory of Australia a patients medical records must be stored for 25 years. They can only be destroyed under strictly defined rules. Each nursing student must know the applicable rules for his/her state or Territory.
  2. Medical records of Aboriginal Australians cannot be destroyed, ever. They have to be archived. Medical Records of Main stream Australians who have not had significant events or health problems can be destroyed ten years after death.
  3. The term “medical records” includes the electronic medical records e.g. Results of blood gases stored on the data bank of the Blood gals machine. If the computer data is downloaded and the results entered (elsewhere) than the computer records can be destroyed.
  4. If unsure, and you live in the Northern Territory, you can call Health House, and they will help you with some health care issues.

For more information refer to: Legal aspects of documenting patient care for rehabilitation Professionals, Third Edition, 2006 by Ron W. Scott, EdD, JD, MA (Spanish), PT