The Bellevue Hospital nomenclature of diseases and conditions : with rules for the recording and filing of histories / compiled by the Committee on Clinical Records.

Date:
1911
Catalogue details

Licence: In copyright

Credit: The Bellevue Hospital nomenclature of diseases and conditions : with rules for the recording and filing of histories / compiled by the Committee on Clinical Records. Source: Wellcome Collection.

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    Rules lor the Recording and Filing ol Histories.* 1. All cards, charts, or other blank forms used in obtaining clinical records of patients must be approved by the Committee on Clinical Records and issued from the Record Room. 2. The Admitting Clerk upon the admission of a patient shall fill out the sociological data upon the ob- verse of the bedside card legibly in black ink. 3. The bedside card shall be delivered at once to the Nurse in charge of the ward to which the patient is as- signed. 4. The Nurse in charge of the ward shall verify when, and as soon as possible, the sociological data on the bedside card. 5. If any change or addition to the data becomes necessary, the bedside card with the indicated change must be returned at once to the admitting office for cor- rection. After correction, the bedside card must be returned immediately to the ward. 6. If the patient be transferred to another ward in the hospital the Physician or Surgeon making the transfer must sign the bedside card in the place provided therefor. 7. The bedside card and the history must accompany the patient when transferred from one ward to another. 8. The House Surgeon or Physician shall ascertain as soon as possible the alleged character of the violence in all cases of injury and indicate this character by placing a circle around the appropriate printed number on the reverse of the bedside card. *See also Rales for Recording Operations on page 130.