Nursing hi nursing

CHARTING

USES FOR THE MEDICAL RECORD

PERMANENT ACCOUNT

TRACKS PT PROGRESS/CARE GIVEN

SHARING INFORMATION

PATIENT CONFIDENTIALITY

QUALITY ASSURANCE

ACCREDITATION

6 ITEMS THAT MUST BE DOCUMENTED

INSURANCE REIMBURSEMENT

RESEARCH

LEGAL EVIDENCE FOR MALPRACTICE SUITS

ASSURES CONTINUITY OF CARE

USES FOR THE MEDICAL RECORD

PERMANENT RECORD

WRITTEN IN CHRONOLOGICAL ORDER

FILED IN MEDICAL RECORDS DEPT FOR FUTURE USE/REFERENCE

USES FOR THE MEDICAL RECORD

SHARING INFORMATION

FACILITATES EXCHANGE OF INFORMATION BETWEEN STAFF

PREVENTS DUPLICATION ERRORS (MEDS, DRESSING CHANGE, ACTIVITY, DIETS, ETC.)

USES FOR THE MEDICAL RECORD

PATIENT CONFIDENTIALITY NEVER LEAVE CHART IN A PUBLIC PLACE. DISCUSS CONTENTS ONLY WITH PERSONS

DIRECTLY INVOLVED IN THE PATIENT’S CARE OR THOSE THAT ARE AUTHORIZED BY THE PATIENT. THESE PEOPLE SHOULD BE LISTED BY NAME.

ASK FOR ID PRIOR. DO NOT DISCUSS PT OR PT INFO IN PUBLIC

PLACES, EG. ELEVATORS, CAFTERIA.

USES FOR THE MEDICAL RECORD

QUALITY ASSURANCE

A PEER REVIEW PROCESS CONDUCTED BY A STAFF NURSE AND PHYSICIAN

ESTABLISHES AND REFLECTS AGENCY STANDARDS

USES FOR THE MEDICAL RECORD

SIX ITEMS THAT NURSES MUST DOCUMENT

ASSESSMENTNURSG DX AND PT NEEDS INTERVENTIONSCARE PROVIDED PT RESPONSE TO CARE PTS ABILITY TO MANAGE CONTINUING

CARE AFTER DISCHARGE

USES FOR THE MEDICAL RECORD

REIMBURSEMENT

LACK OF DOCUMENTATION MAY RESULT IN DENIAL FOR PAYMENTS FROM MEDICARE AND PRIVATE INSURANCE COMPANIES. THIS PUTS THE BURDEN OF PAYMENT ON THE PATIENT.

USES FOR THE MEDICAL RECORD

RESEARCHDATA ON TREATMENTS, MEDS, AND

THERAPY INFO FOR TUMOR BOARDS, DOCTOR’S

ROUNDS, NURSING ROUNDS, ETC.BE AWARE OF PRIVACY ISSUESNURSES, STUDENT NURSES USE FOR

CARE PLANS.

USES FOR THE MEDICAL RECORD

LEGAL EVIDENCE RECORDS ARE CONSIDERED LEGAL OR

POTENTIAL LEGAL DOCUMENTS MAY BE SUBPEONAED AS EVIDENCE BY

ATTORNEY OR NURSING BOARDS. CHECK FOR DEVIATIONS FROM FACILITY POLICY OR STANDARDS.

EACH HEALTH CARE PROVIDER IS RESPONSIBLE FOR THE ABC’S OF RECORDING. ACCURACY, BRIEF, COMPLETE.

ACCESS TO CHARTS

PATIENT’S RIGHTS

WHO OWNS CHART

AGENCY POLICY

ACCESS TO CHARTS

PATIENT’S RIGHTS/AGENCY POLICY

PATIENTS HAVE THE RIGHT TO THE INFO IN THEIR CHARTS.

THEY DO NOT HAVE THE RIGHT TO SEE THE CHART ON DEMAND OR REMOVE ANYTHING FROM THE CHART, OR REMOVE THE CHART FROM THE FACILITY.

ACCESS TO CHARTS

WHO OWNS THE CHART

A PATIENT’S CHART IS THE PROPERTY OF THE FACILITY. IT IS THE FACILITY WHICH SETS THE POLICY AND MAKES APPOINTMENTS FOR VIEWING OF THE CHART.

TYPES OF PATIENT RECORDS

SOURCE-ORIENTED

PROBLEM-ORIENTED

TYPES OF PATIENT RECORDS

SOURCE ORIENTEDMOST TRADITIONALDIFFERENT DISCIPLINES CHART ON

SEPARATE FORMS.EACH READER MUST CONSULT VARIOUS

PARTS OF THE RECORD TO GET A COMPLETE PICTURE.

RECORDS BECOMES BULKY.

TYPES OF PATIENT RECORDS

PROBLEM ORIENTEDCOMMONLY REFERRED TO AS POR.ORGANIZED ACCORDING TO PROBLEM.FOUR PARTS:

A. DATA BASE. THE PATIENTS PRESENT HEALTH STATUS.

B. PROBLEM LIST. NUMBERED LIST OF HEALTH PROBLEMS.

C. INITIAL PLAN. PLAN TO HELP OVERCOME HEALTH PROBLEMS.

D. PROGRESS NOTES. ALL DISCIPLINES CHART ON SAME PAGE.

METHODS (STYLES) OF CHARTING

NARRATIVE SOAP

SOAPIER FOCUS

DATA

ACTION

RESPONSE PIE EXCEPTION CHARTING

NARRATIVECHRONOLOGICALBASELINE CHARTED QSHIFT

LENGTHY, TIME-CONSUMING

SEPARATE PAGES FOR EACHSOURCE-ORIENTED

SOAP USED FOR PROBLEM-ORIENTED CHARTS

S – SUBJECTIVE. WHAT PT TELLS YOU. 0 – OBJECTIVE. WHAT YOU OBSERVE, SEE. A – ASSESSMENT. WHAT YOU THINK IS GOING ON

BASED ON YOUR DATA. P – PLAN. WHAT YOU ARE GOING TO DO.

CAN ADD TO BETTER REFLECT NURSING PROCESS I – INTERVENTION (SPECIFIC INTERVENTIONS

IMPLEMENTED) E – EVALUATION. PT RESPONSE TO INTERVENTIONS. R – REVISION. CHANGES IN TREATMENT.

EXAMPLE OF SOAP CHARTING

#1 ALTERATION IN COMFORT. ABDOMINAL PAIN.

S – COMPLAINS OF PAIN IN RUQ

O – IS PALE AND HOLDING RIGHT SIDE

A – RECURRING ABDOMINAL PAIN

P – PUT ON NPO AND NOTIFY PHYSICIAN

FOCUS CHARTING

USES NARRATIVE DOCUMENTATION (DAR)

DATA – SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE FOCUS (CONCERN)

ACTION – NURSING INTERVENTION

RESPONSE – PT RESPONSE TO INTERVENTION

EXAMPLE OF FOCUS CHARTING

D – COMPLAINING OF PAIN AT INCISION SITE ON LEVEL OF #7

A – REPOSITIONED FOR COMFORT. DEMEROL 50MG IM GIVEN.

R – (CHARTED AT A LATER DATE.) STATES A DECREASE IN PAIN, “FEELS MUCH BETTER.”

PIE CHARTINGSimilar to SOAP chartingBoth are problem-orientedPIE comes from the Nursing Process,

SOAP comes from a Medical Model.P-ProblemI-InterventionE-Evaluation

SAMPLE OF PIE CHARTING

P#1 Risk for trauma related to dizziness.

IP#1 Instructed to call for assistance when

getting OOB. Call light in reach.

EP#1 Consistently call for assistance

before getting OOB. Continues to

experience dizziness.

CHARTING BY EXCEPTION

USES FLOWSHEETS

EMPHASIS ON ABNORMAL (WHAT IS ABNORMAL FOR THIS PATIENT.

ALTHOUGH IT MAY BE ABNORMAL FOR THE “NORMAL” PERSON, IF IT IS ABNORMAL FOR YOUR PATIENT ON A CONSISTENT BASIS, IT IS NO LONGER CONSIDERED AN “EXCEPTION”.

ADVANTAGE

COMPUTERIZED CHARTING

PASSWORD. NEVER SHARE. CHANGE FREQUENTLY. LEGIBLE CAN BE VOICE-ACTIVATED, TOUCH-ACTIVATED. DATE AND TIME AUTOMATICALLY RECORDED. ABBREVIATIONS AND TERMS ARE SELECTED BY A MENU

PROVIDED BY THE FACILITY. TERMINALS ARE USUALLY EASILY ACCESSIBLE, IN PT ROOMS,

CONVENIENT HALLWAY LOCATIONS. MAKE SURE TERMINAL CANNOT BE VIEWED BY

UNAUTHORIZED PERSONS.

KARDEX

QUICK REFERENCE

CHANGED AS NEEDED

NOT PART OF PERMANENT RECORD

ABBREVIATIONS

YOU MUST USE YOUR FACILITY’S APPROVED ABBREVIATIONS.

BE AWARE THAT A LOT OF COMMONLY USED ABBREVIATIONS: EG. TID, BID, QOD, HS ARE NO LONGER ALLOWED AND SHOULD BE CURRENTLY BEING PHASED OUT OF YOUR FACILITY.

CHANGE OF SHIFT REPORT

PERSON TO PERSON

BE PREPAREDAVOID

GOSSIP/SOCIALIZATION

TAPE RECORDER

INCIDENT REPORTS

OBJECTIVE DO NOT BLAME OR

ADMIT LIABILITY WHAT DID YOU DO? DO NOT INCLUDE

NAMES/ADDRESSES OF WITNESSES

DOCUMENT TIME/NAME OF DOCTOR

DO NOT FILE IN CHART DO NOT WRITE “INCIDENT

REPORT MADE”

CORRECTING ERRORS

IF YOU SPILL SOMETHING ON THE CHART, DO NOT DISCARD NOTES. RECOPY, PUT ORIGINAL AND COPIED SHEETS IN CHART. WRITE “COPIED” ON COPY.

DO NOT SCRIBBLE OUT CHARTING.

AVOID USING “ERROR” OR “WRONG PATIENT” WHEN MAKING CORRECTION.

FOLLOW YOUR FACILITIES POLICY.

DO NOT ALTER CHARTING, IT IS A LEGAL DOCUMENT.