Class 10: Intro to charting Flashcards
charting by exception
is that a patient meets all standards unless otherwise documented. method was introduced in the early 1980’s
confidentiality
nurses must follow certain principles to maintain confidentiality of patients
consultations
form of discussion where one professional caregiver gives formal advice about the care of a patient to another care giver
Data-Action-Response-Plan (DARP)
data (subjective and objective
action or nursing intervention
response of the patient (evaluation of effectiveness)
adresses patient convers: a sign or symptom, condition, nursing diagnoses, behaviour, significant event, or change in patients condition
documentation systems
a nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions and patient responses in a health record
health care record
or chart, is confidential, permenant legal record of info relevant to patients health care.
kardex
portable “flip over” file or binder is kept at nursing station
personal info protection and electronic documents act (PIPEDA)
federal legislation that protects personal info, including health info. describes how private-sector organizations may collect, use or disclose personal in the course of commercial activities
referrals
an arrangement for services by another care provider
reports
oral, written or audiotaped exchanged of information between caregivers
standardized care plan
used to make documentation easier for nurses, only used in some institutions. they are preprinted, established guidelines that are used to care for patients with similar health problems
subjective-objective-assessment-plan (SOAP)
subjective data (verbalizations of the patient) objective data (measured and observed) assessment (diagnosis based on data) plan (what the caregiver plans to do)
WNL
within normal limits
purpose of reporting
- facilitates communication between health care providers for continuity of care
- guides professional and organizational performance improvement
- maintains a legal record of care
- to limit liability, nursing documentation must clearly indicate that care was given and based on nursing assessment
quality documentation and reporting
- factual
- accurate
- complete
- current
- organized
- confidential
factual reporting and documentation
descriptive and objective. avoid charting routine, superficial or irrelevant info.
- write down using quotation makes and clients exact words or paraphrased without quotations
- client demonstrating increased agitation, increased pulse and respirations rates NOT client seems anxious.
- client appeared to be sleeping on all rounds, respirations WNL. NOT client slept well.
accurate reporting and documentation
use precise measurements. use institution accepted abbreviations, symbols, and systems of measurement
- avoid misunderstanding by writing in full any abbreviations that may be confusing (OD, od)
- correct spelling is critical, it demonstrates competency and decreases confusion
- record is ended with the writers first initial last name, and status including student (O. Skrodolis, CCPNS)
complete reporting and documentation
complete and thorough
-a great deal of info recorders in narrative when more detail is required
current reporting and documentation
makes entries promptly and record late entries correctly (e.g. “1100 (late entry for 0845)”
- client reported seizure activity. medication given with good effect, no further seizure activity reported or observed at this time.
- some entries must be recorded as they happen VS, pain assessment, medication admin, change in status, admission, discharge, transfer, death
organized reporting and documentation
write in logical order. be concise, clear and to the point.
progress notes (methods of recording)
ongoing record of monitoring of a patient progress by members of the health care team
narrative notes (methods of recording)
traditional method, uses a story life format
disadvantages of methods of recording
tendency to repeat info, time consuming, requires the reader to sort through much info to locate desired data
O/E
on examination
C/O
complained of
NYD
not yet diagnosed
B.R.
bed rest
BRP
bathroom privileges
subcut
subcutaneous
charting by exception
- ONLY chart when something is out of the ordinary occurs and the info cannot be relayed on flow sheets
- info that is unchanged from the previous day is not documented. e.g. ADL’s, meals, activities
confidential reporting and documentation
all documentation and recording stays within the health care setting. make references to other clients by initials
basic rules for charting
- factual, accurate, current, complete, organized, confidence.
- all sheets have correct name, date and time
- use only approved abbreviations and medical terms
- write legibly or print
- follow all rules of grammar and punctuation
- fill all spaces, leave no empty lines
- chart after care, not before
- chart as soon and as often as possible
- chart only what you do
- chart facts, avoid judgement terms
- chart each departure and return of pt.
- sign each block of charting with first initial, last name and designation
- chart all ordered care as given or explain deviation
- note response to treatment or analgesics
- note a late entry as such and then proceed with notation
- use names appropriate
fixing mistakes in documenting and charting
remember that charts are LEGAL DOCUMENTS. all writing must be done in PEN (black). No felt pen, gel pen, erasable pen or pencils
-no erasing, scribbling over or white out on docs. any error must have one line drawn through it with the word “error” written along with your initial
what to remember with documenting and charting
if it wasn’t documented… it did not happen. clients charts are the first thing to be scrutinized in cases of malpractice or in charges of negligence
real charting errors
lots of them, spelling is key
