2 Flashcards
• What is documentation? Written recording of pertinent information related to the client.
o Documentation means “to give written information that is proof or support of something that has been done or observed.” Documentation is the written account of observations, the information the client, resident or family relates or states, the data you collect during care, and the care that you provide.
• Identify the legal and ethical considerations of documentation.
o Client’s record is a legal document
o May be used to provide evidence in court
o Documentation provides crucial legal protection. Admissible in court, the patient’s medical record must be documented in an accurate, complete, systematic, logical, concise, and timely manner.
o The medical record is a legal document. In a malpractice case, the jurors usually view the medical record as the best evidence of what really happened. For this reason, all documentation should be neatly written and legible. Illegible handwriting is handwriting that cannot be read or understood by others can be interpreted as poor care.
o DO NOT cover up anything in a chart with white out. Draw one line through it and indicate “error”, and be certain you initial it
o NOTE: if you didn’t chart it, you didn’t do it… has another meaning, if you did not do it, don’t have someone else chart you did what you did not. Also, do not document care provided by someone else. If there is a problem, you will be held liable.
• Identify measures used to maintain confidentiality and the security of information including computerized records
o Restrict access
o Ethical codes and legal responsibility
o Policies and procedures to ensure privacy and confidentiality
o Developed to manage volume of information
o Use of computers to store the client’s database, new data, create and revise care plans, and document client’s progress
o Information easily retrieved
o Possible to transmit information from one care setting to another
• Medical record-
is a collection of information about the person you are caring for. It is a legal and confidential record with pertinent information related to the care provided
Password, log off, don’t leave it on the computer for others to read, proper documentation polices, IT has to install a firewall to protect unauthorized access, inform people if a security breach has occurred
o Source-orientated record
= traditional client record. Each dep. Makes notations on sep. sections in the chart.
o Narrative charting
a descriptive record of client data and nursing interventions, written in sentences and paragraphs.
o Focus charting-
a method of charting that uses
o SBAR-
situation-background- assmessment recommendation; a communication tool commonly used during change-of-shift reports to promote and maintain effective communication between the health care team when discussing a client’s condition and progress
o CBE-
charting by exception, documentation system in which only significant findings or execeptions to norms are recoreded.
mar
o MAR- medication administration record
• Describe guidelines for accepting medical orders by telephone-
date and time, name of person giving the info, the info its self, and signature, read back
Reasons For Careful Documentation
- Documentation gives written evidence of care given, the patient’s response, and the effect of the care.
- Documentation plans for the future care and changes in plan of care so all members can be kept current.
- Documentation serves as a communication tool. When you document, remember that you alone are responsible for noting what was done, and observed.
- Documentation is legal, and reimbursement is often dependent on the notes that are written.
- Documentation allows for continuity of care and focuses on clients needs and goals from all those involved in their care.
- If the chart goes to court, you will most likely go to court too.
KARDEX-
are useful, but need to be maintained and up to date to be of any value. The card system is readily available to all staff who need information at a glance to what is pertinent with the patient. The cards are written in pencil so they can be updated appropriately and easily.
NARRATIVE CHARTING -
The nurse documents in chronological order the events that took place throughout the shift. Narrative charting is time consuming, so make certain your notes are legible and clear to understand by all who reads them.
A note should be made at least every two hours.
soap notes
This method is preferred by many nurses. It stands for Subjective data, Objective data, Assessment, and Plan. Sometimes it can be referred to as SOAPIE or SOAPIER, in which the “I” indicates implementation and “E” indicated Evaluation. When an “R” is included, this indicates Revision.
