Charting Flashcards
1
Q
Types of charting
A
- Progress notes
- Charting by exception
- Charting in forms (values, assessments, evaluations, plans like tnp)
2
Q
Reasons for charting
A
- Communication
- Accountability
- Care planning and continuity of care
- Legality
- Education
- Research
- Auditing for quality assurance
3
Q
Legal and ethical standards for documentation
A
- Pt charts are legal documents
- Can be called into court
- Must be objective (no “i”)
- Documentation of NP
- Not charted = not done
- Injury/death
- Treatment refusal
- Confidentiality
4
Q
A
5
Q
Charting should be
A
- Accurate
- Factual and appropriate
- Concise, brief and complete
- Legible
- Current
- Organized
- Compliant with ethical and legal organization documentation standards
6
Q
Charting rules (must have)
A
- Begin with date and time
- Use 24:00 clock
- Identify discipline
- Sign you name off (Z. Lauzé S.N Dawson College)
- Chart throughout shift (diff entries)
- Use commonly approved abbreviations (ex PRN)
- No speculations
- Quote pt/family statements
- Avoid personal opinion
7
Q
Late entry rules
A
- Write time when writing late entry (not time it happened)
- Write time and date of late entry in progress note (ex LATE ENTRY from 25/02/02 at 17:48)
8
Q
Do nots in charting
A
- Pre-chart
- Record errors made by physician on order
- Document for others
- Use generalized statements
- Use white-out or scratch out errors written
9
Q
What is in a chart
A
- Pt data
- Consent
- Admission history
- TNP
- Progress notes
- Medical order
- Flow sheets
- Diagnostic studies
10
Q
Types of progress notes
A
- Problem focused (ex DARP)
- Charting by exception (usually flow sheets)
- Narrative charting
11
Q
A
12
Q
Charting by exception is based on
A
- Defined standards of practice
- Pre determined criteria for nursing assessments and interventions
- Only significant findings or exceptions to the norm documented
- Checkmarks used if all is normal
13
Q
Charting by exception (CBE)
A
- Nursing documentation time is cut significantly
- Abnormal findings are highlighted
- Documentation of routine care is eliminated through the use of nursing standards
- Ppt data written when collected
- Assessments are standardized
- No duplication of info
14
Q
Problem focused notes
A
Focus:
1. Sign/symptom or condition
2. Pt behaviour
3. Significant event/change in pt condition
4. Follows nursing process
15
Q
Darp
A
D: data (subjective and objective related to focus)
A: action (nurse in response to data)
R: response (pt)
P: plan (ongoing care)
16
Q
Narrative charting
A
- Story-like format to document client specific info
- Organized to a standard framework
