Charting Flashcards
what are the purposes of Charting?
communication between health care professionals accountability Legal requirement of the profession Planning and continuity of care auditing for quality assurance education research
What is charting?
a confidential permanent legal documentation of information relevant to a patient’s health care
who is the chart available to?
Available to all members of the health team
not available to PAB’s
All documents should be
accurate factual concise legible current organized complies
How do you ensure documentation is accurate?
subjective data should be in quotes
you are accountable for what you chart
never chart as someone else
correct pt biographical info
how do you ensure your charting is factual?
document facts and observations
document relevant information
do not write critical comments
avoid misinterpreted statements
how do you ensure your charting is concise?
document all assessments, nursing diagnoses, interventions and pt responses and concerns
document refused care
clarify separate thoughts
how do you chart the entry date and time?
year/month/day and use 24hr clock for time of intervention and time that you are charting
how do you correct errors?
draw a single line through error
initial note
How do you record late entries?
must clearly record as late entry and not the time
how do you finish your documentation?
finish by writing your signature + SN Dawson college
