Nursing Skills: Charting

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  1. CHARTING
  2. USES FOR THE MEDICAL RECORD
    • PERMANENT ACCOUNT
    • TRACKS PT PROGRESS/CARE GIVEN
    • SHARING INFORMATION
    • PATIENT CONFIDENTIALITY
    • QUALITY ASSURANCE
    • ACCREDITATION
    • 6 ITEMS THAT MUST BE DOCUMENTED
    • INSURANCE REIMBURSEMENT
    • RESEARCH
    • LEGAL EVIDENCE FOR MALPRACTICE SUITS
    • ASSURES CONTINUITY OF CARE
  3. USES FOR THE MEDICAL RECORD
    • PERMANENT RECORD
    • WRITTEN IN CHRONOLOGICAL ORDER
    • FILED IN MEDICAL RECORDS DEPT FOR FUTURE USE/REFERENCE
  4. USES FOR THE MEDICAL RECORD
    • SHARING INFORMATION
    • FACILITATES EXCHANGE OF INFORMATION BETWEEN STAFF
    • PREVENTS DUPLICATION ERRORS
    • (MEDS, DRESSING CHANGE, ACTIVITY, DIETS, ETC.)
  5. USES FOR THE MEDICAL RECORD
    • PATIENT CONFIDENTIALITY
    • NEVER LEAVE CHART IN A PUBLIC PLACE.
    • DISCUSS CONTENTS ONLY WITH PERSONS DIRECTLY INVOLVED IN THE PATIENT’S CARE OR THOSE THAT ARE AUTHORIZED BY THE PATIENT. THESE PEOPLE SHOULD BE LISTED BY NAME.
    • ASK FOR ID PRIOR.
    • DO NOT DISCUSS PT OR PT INFO IN PUBLIC PLACES, EG. ELEVATORS, CAFTERIA.
  6. USES FOR THE MEDICAL RECORD
    • QUALITY ASSURANCE
    • A PEER REVIEW PROCESS CONDUCTED BY A STAFF NURSE AND PHYSICIAN
    • ESTABLISHES AND REFLECTS AGENCY STANDARDS
  7. USES FOR THE MEDICAL RECORD
    • ACCREDITATION
    • JCAHO (JOINT COMMISSION ON ACCREDITATION OF HEALTH ORGANIZATION)/DSHS STATE (EXTENDED CARE)
    • SETS MINIMUM STANDARDS FOR STAFFING
    • THE AMERICAN NURSE’S ASSOCIATION SETS THE STANDARDS FOR PT CARE & DOCUMENTATION FOR NURSE’S
  8. USES FOR THE MEDICAL RECORD
    • SIX ITEMS THAT NURSES MUST DOCUMENT
    • ASSESSMENT
    • NURSG DX AND PT NEEDS
    • INTERVENTIONS
    • CARE PROVIDED
    • PT RESPONSE TO CARE
    • PTS ABILITY TO MANAGE CONTINUING CARE AFTER DISCHARGE
  9. USES FOR THE MEDICAL RECORD
    • REIMBURSEMENT
    • LACK OF DOCUMENTATION MAY RESULT IN DENIAL FOR PAYMENTS FROM MEDICARE AND PRIVATE INSURANCE COMPANIES. THIS PUTS THE BURDEN OF PAYMENT ON THE PATIENT.
  10. USES FOR THE MEDICAL RECORD
    • RESEARCH
    • DATA ON TREATMENTS, MEDS, AND THERAPY
    • INFO FOR TUMOR BOARDS, DOCTOR’S ROUNDS, NURSING ROUNDS, ETC.
    • BE AWARE OF PRIVACY ISSUES
    • NURSES, STUDENT NURSES USE FOR CARE PLANS.
  11. USES FOR THE MEDICAL RECORD
    • LEGAL EVIDENCE
    • RECORDS ARE CONSIDERED LEGAL OR POTENTIAL LEGAL DOCUMENTS
    • MAY BE SUBPEONAED AS EVIDENCE BY ATTORNEY OR NURSING BOARDS. CHECK FOR DEVIATIONS FROM FACILITY POLICY OR STANDARDS.
    • EACH HEALTH CARE PROVIDER IS RESPONSIBLE FOR THE ABC’S OF RECORDING. ACCURACY, BRIEF, COMPLETE.
  12. ACCESS TO CHARTS
    • PATIENT’S RIGHTS
    • WHO OWNS CHART
    • AGENCY POLICY
  13. ACCESS TO CHARTS
    • PATIENT’S RIGHTS/AGENCY POLICY
    • PATIENTS HAVE THE RIGHT TO THE INFO IN THEIR CHARTS.
    • THEY DO NOT HAVE THE RIGHT TO SEE THE CHART ON DEMAND OR REMOVE ANYTHING FROM THE CHART, OR REMOVE THE CHART FROM THE FACILITY.
  14. ACCESS TO CHARTS
    • WHO OWNS THE CHART
    • A PATIENT’S CHART IS THE PROPERTY OF THE FACILITY. IT IS THE FACILITY WHICH SETS THE POLICY AND MAKES APPOINTMENTS FOR VIEWING OF THE CHART.
  15. TYPES OF PATIENT RECORDS
    • SOURCE-ORIENTED
    • PROBLEM-ORIENTED
  16. TYPES OF PATIENT RECORDS
    • SOURCE ORIENTED
    • MOST TRADITIONAL
    • DIFFERENT DISCIPLINES CHART ON SEPARATE FORMS.
    • EACH READER MUST CONSULT VARIOUS PARTS OF THE RECORD TO GET A COMPLETE PICTURE.
    • RECORDS BECOMES BULKY.
  17. TYPES OF PATIENT RECORDS
    • PROBLEM ORIENTED
    • COMMONLY REFERRED TO AS POR.
    • ORGANIZED ACCORDING TO PROBLEM.
    • FOUR PARTS:
    • A. DATA BASE. THE PATIENTS PRESENT HEALTH STATUS.
    • B. PROBLEM LIST. NUMBERED LIST OF HEALTH PROBLEMS.
    • C. INITIAL PLAN. PLAN TO HELP OVERCOME HEALTH PROBLEMS.
    • D. PROGRESS NOTES. ALL DISCIPLINES CHART ON SAME PAGE.
  18. METHODS (STYLES) OF CHARTING
    • NARRATIVE
    • SOAP
    • SOAPIER
    • FOCUS
    • DATA
    • ACTION
    • RESPONSE
    • PIE
    • EXCEPTION CHARTING
  19. NARRATIVE
    • CHRONOLOGICAL
    • BASELINE CHARTED QSHIFT
    • LENGTHY, TIME-CONSUMING
    • SEPARATE PAGES FOR EACH
    • SOURCE-ORIENTED
  20. SOAP
    • USED FOR PROBLEM-ORIENTED CHARTS
    • S – SUBJECTIVE. WHAT PT TELLS YOU.
    • 0 – OBJECTIVE. WHAT YOU OBSERVE, SEE.
    • A – ASSESSMENT. WHAT YOU THINK IS GOING ON BASED ON YOUR DATA.
    • P – PLAN. WHAT YOU ARE GOING TO DO.
    • CAN ADD TO BETTER REFLECT NURSING PROCESS
    • I – INTERVENTION (SPECIFIC INTERVENTIONS IMPLEMENTED)
    • E – EVALUATION. PT RESPONSE TO INTERVENTIONS.
    • R – REVISION. CHANGES IN TREATMENT.
  21. EXAMPLE OF SOAP CHARTING
    • #1 ALTERATION IN COMFORT. ABDOMINAL PAIN.
    • S – COMPLAINS OF PAIN IN RUQ
    • O – IS PALE AND HOLDING RIGHT SIDE
    • A – RECURRING ABDOMINAL PAIN
    • P – PUT ON NPO AND NOTIFY PHYSICIAN
  22. FOCUS CHARTING
    • USES NARRATIVE DOCUMENTATION (DAR)
    • DATA – SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE FOCUS (CONCERN)
    • ACTION – NURSING INTERVENTION
    • RESPONSE – PT RESPONSE TO INTERVENTION
  23. EXAMPLE OF FOCUS CHARTING
    • D – COMPLAINING OF PAIN AT INCISION SITE ON LEVEL OF #7
    • A – REPOSITIONED FOR COMFORT. DEMEROL 50MG IM GIVEN.
    • R – (CHARTED AT A LATER DATE.) STATES A DECREASE IN PAIN, “FEELS MUCH BETTER.”
  24. PIE CHARTING
    • Similar to SOAP charting
    • Both are problem-oriented
    • PIE comes from the Nursing Process, SOAP comes from a Medical Model.
    • P - Problem
    • I -Intervention
    • E -Evaluation
  25. SAMPLE OF PIE CHARTING
    • P#1 Risk for trauma related to dizziness.
    • IP#1 Instructed to call for assistance when
    • getting OOB. Call light in reach.
    • EP#1 Consistently call for assistance
    • before getting OOB. Continues to
    • experience dizziness.
  26. CHARTING BY EXCEPTION
    • USES FLOWSHEETS
    • EMPHASIS ON ABNORMAL (WHAT IS ABNORMAL FOR THIS PATIENT.
    • ALTHOUGH IT MAY BE ABNORMAL FOR THE “NORMAL” PERSON, IF IT IS ABNORMAL FOR YOUR PATIENT ON A CONSISTENT BASIS, IT IS NO LONGER CONSIDERED AN “EXCEPTION”.
    • ADVANTAGE
  27. COMPUTERIZED CHARTING
    • PASSWORD. NEVER SHARE. CHANGE FREQUENTLY.
    • LEGIBLE
    • CAN BE VOICE-ACTIVATED, TOUCH-ACTIVATED.
    • DATE AND TIME AUTOMATICALLY RECORDED.
    • ABBREVIATIONS AND TERMS ARE SELECTED BY A MENU PROVIDED BY THE FACILITY.
    • TERMINALS ARE USUALLY EASILY ACCESSIBLE, IN PT ROOMS, CONVENIENT HALLWAY LOCATIONS.
    • MAKE SURE TERMINAL CANNOT BE VIEWED BY UNAUTHORIZED PERSONS.
  28. KARDEX
    • QUICK REFERENCE
    • CHANGED AS NEEDED
    • NOT PART OF PERMANENT RECORD
  29. ABBREVIATIONS
    • YOU MUST USE YOUR FACILITY’S APPROVED ABBREVIATIONS.
    • BE AWARE THAT A LOT OF COMMONLY USED ABBREVIATIONS: EG. TID, BID, QOD, HS ARE NO LONGER ALLOWED AND SHOULD BE CURRENTLY BEING PHASED OUT OF YOUR FACILITY.
  30. CHANGE OF SHIFT REPORT
    • PERSON TO PERSON
    • BE PREPARED
    • AVOID GOSSIP/SOCIALIZATION
    • TAPE RECORDER
  31. INCIDENT REPORTS
    • OBJECTIVE
    • DO NOT BLAME OR ADMIT LIABILITY
    • WHAT DID YOU DO?
    • DO NOT INCLUDE NAMES/ADDRESSES OF WITNESSES
    • DOCUMENT TIME/NAME OF DOCTOR
    • DO NOT FILE IN CHART
    • DO NOT WRITE “INCIDENT REPORT MADE”
  32. CORRECTING ERRORS
    • IF YOU SPILL SOMETHING ON THE CHART, DO NOT DISCARD NOTES. RECOPY, PUT ORIGINAL AND COPIED SHEETS IN CHART. WRITE “COPIED” ON COPY.
    • DO NOT SCRIBBLE OUT CHARTING.
    • AVOID USING “ERROR” OR “WRONG PATIENT” WHEN MAKING CORRECTION.
    • FOLLOW YOUR FACILITIES POLICY.
    • DO NOT ALTER CHARTING, IT IS A LEGAL DOCUMENT.