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The recording process in the file of a patient is called record keeping, diagram or documentation. The clinical file, which is called as well historical or patients file, is an informal and legal document, which substantiates the care of the patients.
Nursing documentation is entered into a facilitys LTC software for accurate and convenient record keeping. The computerized documentation system allows caregivers to process, share, and access relevant information to provide residents safe and quality care.
Flow sheet and graphic record: These are commonly completed by nurses and include the documentation of physiological data like vital signs, pain, and weight. These records can also include routine documentation related to hygiene, mobility, nutrition, and the use of restraints.
Types of Records Patients Clinical Records. It is the record of events in the patient illness, progress in his or her recovery and the type of care given by the hospi-tal personnel. Individual staff records. Ward Records. Administrative records.
Common formats used to document patient care include charting by exception, focused DAR notes, narrative notes, SOAPIE progress notes, patient discharge summaries, and Minimum Data Set (MDS) charting.

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Medication pass, or med pass, is the term used to describe the process through which medication is administered to patients. While licensed nurses conduct med pass in most cases, in some instances unlicensed nursing staff members take on the role of dispensing medications under the supervision of a nurse.

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