DOCUMENTATION

Documentation

Image by Mundoo via Flickr

 

 

sample of narrative charting

 

 

Head to Toe One patient Two day

Charting Hints

Maintain client confidentiality

Records are confidential and available to health team members only

Records usually requires written permission from the patient to copy or release to another facility or MD office

Respect the client’s right to privacy by protecting confidential information unless obligated or allowed by law to disclose the information.

What to Document

  • ·       client status
  • ·       nursing care rendered
  • ·       orders
  • ·       administration of meds or treatment
  • ·       client response
  • ·       contact with other health care team members

Unprofessional Conduct

Failing to accurately & completely report & document…

Disclosing confidential information or knowledge concerning the client except where required or allowed by law…HIPPA

Purpose of Patient/Client Records

Communication

Quality assurance

Legal documentation

Research

Reimbursement

Accrediting & licensing


Documentation Do’s

Charting should be accurate and appropriate

Write legibly

Maintain confidentiality

Use ink color defined by policy (usually black)

Chart failure of the client to follow treatment regimens & the rational given by the client. Be specific

use direct quotes

Chart in a timely manner – use “late entry” or “addendum” for out of sequence charting

Chart after doing a procedure

Correct errors with a single line and initials

Date, time, and sign with title every entry

Use agency approved abbreviations


Documentation Don’ts

Use non-biased statements

Use the word “client” or “patient”

Never leave blank spaces or lines

Never use white out

Never destroy a page in the chart

Never sign someone else’s name


Content of Documentation

Admit note

Complete assessment

Health history

Subjective & objective data

Change of shift notes

Assessment of client

Narrative or flow sheets

Interval or progress notes

Changes in client status, tests, procedures, PRN medications

Transfer & discharge notes; how was the client moved? with whom? condition?

Client teaching notes

MARs

VS flow sheets

Valuables- disposition of and describe in general terms (gold colored/clear stone)

Spiritual care

Record spiritual distress

Symbols or articles with spiritual meaning

Expressions of grief

Safety concerns

Side rails up if needed

Instructions for safety if given

Check on restrained patients q2hrs

Ambulation assist with documentation of assist for safety, including clothing, devices

Instruction for call light, bed controls


Charting in Different Facilities

In your clinical orientation to each facility you will be oriented to which format  to use

Type of charting will be documented in the policy and procedure manual

Documentation Format

Narrative

Problem focused

PIE, APIE

Focus

SOAP (IER)

Charting by exception (CBE)


Problem Oriented Medical Record (POMR)

All health care providers chart together

Uses data base, problem list, initial plans for problems, & progress notes

All use a problem list & make it specific to the health care providers emphasis


Source Oriented Medical Record (SOMR)

Each health care discipline with section in chart i.e. nurse notes, physician progress notes, physical therapy, etc


Narrative Charting

Narration or narrative description of care provided

Chronological order

Pros & cons

Time consuming to write

Difficulty tracking progress and outcomes

Information related to a specific problem is found in multiple places


APIE Charting

Assessment, planning, implementation, evaluation

Documentation


PIE Charting

Planning, implementation, evaluation


Focus Charting

DAR: data, action, response

DAE: data, action, evaluation

Focuses on client needs from variety of perspectives


SOAP(IER) Charting/Notes

Problem oriented medical record format

SOAP

Subjective, Objective, Assessment, Planning, Implementation, Evaluation, Revision

Advantage – uniform problem list

Disadvantage – lack of flexibility, with all documentation directed to a specific problem


Charting by Exception (CBE)

Chart exceptions to the norm

Use of flowsheets

Checklists

Use of narrative notes r/t exceptions


Computer Based Records

Contain information identical to CBE

Eliminates repetitive entries

Confidentiality is a concern – HIPPA

Makes entries easier


Flow Sheets or Checklists

Most facilities use flow sheets and checklists to document routine care

These sheets are time savers, and are part of the patient record, thus a legal record admissible in court

Vital signs

Intake & output (I/O)

Post operative assessment

Physical assessment

ADLs/Hygiene

Diet/Nutrition

Elimination

Minimize time spent charting

Safety issues

Documentation


Standardized Assessment Forms or Guidelines

Standardizes yet vary from agency to agency

Help locate data

Decrease charting time


Nursing Care Plans

Individualized or traditional

Standardized


Clinical/Critical Pathways

Care map

Day to day care

Expected progress


Kardex

Quick reference regarding client care

Used for change of shift report

Diet, activity, hygiene, oxygen, treatments, etc


Facility Specific Documents – UCI

Rounds reports (Grand rounds)

Diagnosis, , medications, tests, research protocol, expected progress, prognosis, Q&A’s, etc

Maintain confidentiality!


MAR (medication administration record)

Scheduled medicines

Non scheduled/PRN medicines


Reporting

Change of shift reports

Taped reports

Incident/Variance Report


Taped Reports

Taped report is done at the end of the shift

Don’t- tape value judgments about clients

Don’t- tape jokes about events happening on the floor (tape may be confiscated and used against you)

Do-stick to the facts about the care needs of the clients

Do be brief and concise; don’t vent your frustration on tape


Incident/Variance Report

Used to document “unusual occurrence”

Chart what happened in nurses notes

DO NOT chart that incident report exists!!!


Verbal Orders

Avoid verbal orders if possible

If unavoidable, insist on these steps

Make sure the physician dictates slowly and clearly as you write it

Repeat the order back to the physician

Write TO or VO, MD’s name/your name, date, and time the order was given

Review Calculation of Drug Dosages

Discussion

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