Class 10: Intro to charting

Question 1

charting by exception

Answer 1

is that a patient meets all standards unless otherwise documented. method was introduced in the early 1980’s

Question 2

confidentiality

Answer 2

nurses must follow certain principles to maintain confidentiality of patients

Question 3

consultations

Answer 3

form of discussion where one professional caregiver gives formal advice about the care of a patient to another care giver

Question 4

Data-Action-Response-Plan (DARP)

Answer 4

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

Question 5

documentation systems

Answer 5

a nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions and patient responses in a health record

Question 6

health care record

Answer 6

or chart, is confidential, permenant legal record of info relevant to patients health care.

Question 7

kardex

Answer 7

portable “flip over” file or binder is kept at nursing station

Question 8

personal info protection and electronic documents act (PIPEDA)

Answer 8

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

Question 9

referrals

Answer 9

an arrangement for services by another care provider

Question 10

reports

Answer 10

oral, written or audiotaped exchanged of information between caregivers

Question 11

standardized care plan

Answer 11

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

Question 12

subjective-objective-assessment-plan (SOAP)

Answer 12

subjective data (verbalizations of the patient)
objective data (measured and observed)
assessment (diagnosis based on data)
plan (what the caregiver plans to do)

Question 13

WNL

Answer 13

within normal limits

Question 14

purpose of reporting

Answer 14

• 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

Question 15

quality documentation and reporting

Answer 15

1. factual
2. accurate
3. complete
4. current
5. organized
6. confidential

Question 16

factual reporting and documentation

Answer 16

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.

Question 17

accurate reporting and documentation

Answer 17

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)

Question 18

complete reporting and documentation

Answer 18

complete and thorough

-a great deal of info recorders in narrative when more detail is required

Question 19

current reporting and documentation

Answer 19

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

Question 20

organized reporting and documentation

Answer 20

write in logical order. be concise, clear and to the point.

Question 21

progress notes (methods of recording)

Answer 21

ongoing record of monitoring of a patient progress by members of the health care team

Question 22

narrative notes (methods of recording)

Answer 22

traditional method, uses a story life format

Question 23

disadvantages of methods of recording

Answer 23

tendency to repeat info, time consuming, requires the reader to sort through much info to locate desired data

Question 24

O/E

Answer 24

on examination

Question 25

C/O

Answer 25

complained of

Question 26

NYD

Answer 26

not yet diagnosed

Question 27

B.R.

Answer 27

bed rest

Question 28

BRP

Answer 28

bathroom privileges

Question 29

subcut

Answer 29

subcutaneous

Question 30

charting by exception

Answer 30

• 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

Question 31

confidential reporting and documentation

Answer 31

all documentation and recording stays within the health care setting. make references to other clients by initials

Question 32

basic rules for charting

Answer 32

1. factual, accurate, current, complete, organized, confidence.
2. all sheets have correct name, date and time
3. use only approved abbreviations and medical terms
4. write legibly or print
5. follow all rules of grammar and punctuation
6. fill all spaces, leave no empty lines
7. chart after care, not before
8. chart as soon and as often as possible
9. chart only what you do
10. chart facts, avoid judgement terms
11. chart each departure and return of pt.
12. sign each block of charting with first initial, last name and designation
13. chart all ordered care as given or explain deviation
14. note response to treatment or analgesics
15. note a late entry as such and then proceed with notation
16. use names appropriate

Question 33

fixing mistakes in documenting and charting

Answer 33

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

Question 34

what to remember with documenting and charting

Answer 34

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

Question 35

real charting errors

Answer 35

lots of them, spelling is key