Charting Flashcards
What to do with a verbal order
Write it down and have a dr sign it
Students are not allowed to take verbal orders
Static Charting
Approved/standardized forms and basic charting
The legal stuff
Chart serves as
Legal record of what has occurred Communication between disciplines All documentation must meet accreditation standards All will be subject to chart audits A means to bill insurance
Charting Principals
Always date and time entries with 24 hour clock
Be specific, brief, and through,
be accurate, objective, and honest
Use correct tense and chart in chronological order
Electronic Charts require 3 elements
Protection of pt. information
People that access the information must be tracked
Files are interactive with medical information
EMR
Electronic Medical Record
Site of care delivery methods of data storage for patient information
EHR
Electronic Health Record
Comprehensive health records the pt. that is accessible across multiple facilities and care settings
PHR
Personal Health Record
A pt. centered portal that pt. and health care providers ccan access
Advantage of Electronic Charting
Recordability
Portability
Reliability
Disadvantage of Electronic Charting
Power failures
Communication between platforms
security
Costly
Focus Charting
Brief narrative of information that is the common form of charting in AHS
Problem/task oriented with a pt. focus
Support team collaboration
Intention of focus charting
Reflect clinical decision making and critical though process for though decision
Reflect pt. status, treatment, with changes and improvement
FOCUS in focus charting
FOCUS is the reason for therapy Pt. Concern Pt. condition, symptom, and presentation A significance event or episode Will describe the condition or event and not the treatment that is being taken
Focus charting orientation
Oriented to specific symptoms
Or may be orientated to a specific body system
FDARP Charting
Focus-Why you are there Data-IPPA Action-What steps are taken (intervention and treatment) Response/Reaction Plan-Follow up
