Charting Flashcards
What is charting?
A confidential, permanent legal documentation of information relevant to a patient’s health care.
Who is the chart available too?
Available to all members of the health team
not available to PAB’S
Purpose of patient chart?
Communication between team members Care planning and continuity of care Legal document Education Research Auditing for Quality Assurance
Chart Contents?
Patient identification and demographic data
Informed consent
Admission Nursing History
Nursing Care Maps
TNP (Therapeutic Nursing Plan)
Progress Notes (usually interdisciplinary) Medical History with diagnosis
Medical Orders
Reports of physical examinations, consultations and diagnostic studies
Flow sheets/ Graphic sheets
Summary of operative procedures
Discharge plan and summary
Documentation systems?
problem-oriented documentation
source-oriented documentation
computerized documentation
Source-oriented documentation?
Chart is organized so that each discipline has a separate section in which to record data.
Source-oriented documentation components
Admission sheet Medical order sheet Nursing History Graphic and flow sheets Medical history and exam Nurses notes Medication records Medical progress notes Consultations
Problem-oriented documentation?
emphasizes the client’s problems.
Data organized by problem or diagnosis
Problem-oriented documentation components?
Database
Problem list
Care plan
Progress notes
What are progress notes?
Can be reserved for nursing only (i.e. MCH)-source oriented
Can be multidisciplinary-problem oriented
Nursing notes in progress notes?
Charting by exception (CBE) Problem focused (DARP, SOAP, PIE) or Narrative charting
Computerized Documentation?
Improved uniformity, accuracy and retrievability of data
Confidentiality
Accessibility
Selective retrieval
Assistance with clinical applications.
Availability of a life-long record of health-related events.
Nursing Notes: Charting by Exception (CBE)?
Shorthand method for documenting normal findings (using flowsheets)
Based on:
defined standards of practice
pre-determined criteria for nursing assessments and interventions.
Only significant findings or exceptions to the norm are documented
Checkmark is used if all normal
Charting by Exception (CBE) (Advantages)?
Nursing documentation time is cut significantly.
Abnormal findings are highlighted.
Documentation of routine care is eliminated through the use of nursing standards.
Patient data is written when collected.
Assessments are standardized.
No duplication of information.
Nursing Notes: SOAP(IER)?
Subjective Objective Assessment Plan Intervention Evaluation Revision
Associated with problem-oriented medical record
Origins from medical profession
Nursing Notes: PIE?
PIE
Problem
Intervention
Evaluation
Associated with problem-oriented medical record system
Origin is from nursing process
Nursing Notes: Focus Charting (DARP)?
According to client concern (the focus). Focus: sign, symptom or a condition nursing diagnosis (SCD) medical diagnosis client behaviour significant event/change in the client’s condition. Follows the nursing process.
Nursing Notes: Focus Charting (DAR)?
Data:
Subjective & objective data that relates to focus
Action:
Action that nurse takes in response to her analysis of the data (nursing intervention)
Response:
Client’s response to the nursing intervention
Plan:
Plan for ongoing care
Legal Guidelines for Charting: Dos and Don’ts
DO:
Begin each charting entry with the date and time, identify your discipline.
Ensures correct sequence of events is recorded. (military time, dddd/mm/dd)
End each entry with your full signature and title.
Signature indicates who is accountable for the care delivered.
Chart on each line. If space is left, draw a line horizontally through it and sign your name at the end.
Record all entries legibly and in ink, never use pencil (pencil sometimes used for pt cardex, but it is destroyed when pt is dismissed)
Correct all errors promptly
Chart throughout the day
Record all facts.
Be sure entry is factual; do not speculate or guess
For computer documentation, keep your password to yourself.
Maintains security + confidentiality.
DO NOT:
Erase, use “white-out” or scratch out errors made while recording.
Draw a single line through the error and write the word “error” above it. Initial the note.
Write critical comments about the patient or care by other health care professionals.
Document only objective & factual data.
Incorrect: Extremely large pt was admitted…..
Correct: Pt. weight on admission = 70kg….
“pre-chart”.
Pre-charting invites error and endangers the health and safety of the client.
record that an “error” was made with order.
If an order is questioned, record that clarification was sought.
chart for others.
You are accountable for the information you enter into a chart. Never chart for someone else.
Use generalized, empty phrases such as “status unchanged”, “no complains(C/O) voiced” .
Information is too generalized and has no meaning.
Guidelines for Quality Charting?
Quality documentation and reporting have six important characteristics: Factual Accurate Complete Current Organized Complies with standards
Rules to Remember?
Write legibly and neatly. Use authorized abbreviations. Use proper spelling & grammar. Date all entries and use military time. Write full name and title at the end of your charting entry. Chart promptly after delivery of care.
Progress Notes: Narrative Charting?
use of a story-like format to document client specific info (condition, nursing care)
organized according to a standard framework
takes long, not used frequently
Charting using bio-psychosocial systems:
Respiration / Chest Cardiovascular (or CVS) Nutrition / Diet Urinary elimination (or GU) Intestinal Elimination (or GI) Neuro Mental Status Skin Integrity (or Skin) Wound Dressing Drainage (includes any type of drain) Genitalia Eyes E.N.T. VS IV (site and infusion) CBGM (Capillary Blood Glucose Monitoring) Pain Mobility (includes Musculoskeletal and Activity) Rest Safety Admission Assessment D/C Planning D/C Summary Coping Psychosocial
Other Nursing Documentation?
Flowsheets Nursing Kardexes (client care summary) Discharge Summaries Care Maps/Critical Pathways Therapeutic Nursing Plan (TNP)
