In God we trust, all others must document. Patients record or the chart Three Major Purposes Acts as a vehicle for communication among members of the healthcare team. Documents compliance with standards of care and standards of various accrediting organizations such as JCAHO and the state health department. Documents that patient care meets safe, effective and legal requirements. Ongoing assessment. Patient teaching, including the patients response to teaching and indication that the patient has learned. Response to therapy. Relevant statements made by the patient. Contributes to quality patient care by providing a physical record of the care you provided Facilitates communication between all members of the health care team Acts as a legal safeguard against allegations of negligence and litigation, which why EDs across the country are developing their own specialized documentation forms and systems Timely vital signs. Reporting of changes in patient condition. Medications given. Patient response to medication, treatments and interventions. Discharge teaching. Take time to document accurately, objectively, and thoroughly Be consistent and document legibly If it wasnt documented, it wasnt done. FACTUAL Only information you see, hear or otherwise collect through your senses. Describe, dont label. Be specific. Use neutral language. One of the most common errors in documenting is stating value judgments and not facts. FACTUAL Factual documentation also applies when you make an error. That is, state exactly what you did, or failed to do, that you notified the patients physician and the physicians response. ACCURATE Be precise. Quantify whenever possible COMPLETE Condition change. Patient responses, especially unusual, undesired or ineffective response. Your use of chain-of- command. Communication with patient and family. COMPELETE Make entries in all spaces on all relevant assessment forms. Use N/A or other designation per policy for items that do not apply to your patient. TIMELY Date and time are critical in establishing a timely response to a patient need. Some facilities make timely charting easy by locating the record close to the patient. TIMELY Computer entries are automatically date and time stamped at the time of entry, but if your entry refers to earlier events, be sure that you note the time to which you are referring. The best and safest practice is to document as soon as possible after the event you are documenting. You may forget key pieces of information when rushing through documentation at the end of the shift. Managing a load of many patients may cause you to confuse or forget details. If your documentation is ever reviewed for legal reasons and you have not documented completely, you will be forced to rely on your memory of events. Charting as your shift progresses will help keep your documentation at the end of the shift to a more manageable load. Professionals in other disciplines and nurses who might provide temporary coverage need to have up-to-date information available in the record. HOWEVER, avoid documenting beforehand. This practice is illegal and has contributed to errors and confusion. NEVER document in advance! Too many events can intervene to render your charting inaccurate. Documenting in advance is falsification of a legal record and can have serious consequences in a legal action. Nurses too must exercise vigilance to keep handwriting legible. Clear communication is threatened not only by messy handwriting or handwriting in which all letters look alike, but also by neat, pleasant styles that create ambiguous letters. LETTERS a, c, e, o b, d, f, h, I,k, l, t g, j, q, p, y m, n, r, s u, v, r e, i NUMBERS 2, 7, 8 0, 4, 9 1, 7 3, 8 You may need to slow down to write more clearly. You may need to resort to printing rather than cursive writing. When you encounter illegible handwriting of physicians or others, do not guess the intended meaning. Get clarification! On an obstetric nursing note: The infant was born by virginal delivery. On a nursing note on a medical patient: When she fainted, her eyes rolled around the room. On an admission history and physical: Diagnosis: Atomic dermatitis. Nursing note: The lab test indicated an abnormal lover function. Nursing note: The patient was alert and unresponsive. Pre-surgical note: The patient was to have a bowel resection. However, he took a job as a stockbroker instead. Emergency room note: When the patient was in the ER, she was examined, x-rated, and sent home. Physical therapy note: I saw your patient today who is still under our car. Delivery room note: The baby was delivered, the cord clamped and cut and handed to the pediatrician, who breathed and cried immediately. Mistake Accidentally Somehow Unintentionally Miscalculated Confusing Names of others (roommates) Appears Apparently May be Could be Assume Trailing zeros (Write 5 instead of 5.0, which may be mistaken for 50.). Leading zeros (Write 0.5 instead of.5, which may be mistaken for 5). cc; instead use mL and write out the word unit. ; instead use mcg; often confused for mg. : instead write out less than and greater than. If you are countersigning with a student or another nurse, review carefully the content of the documentation. Similarly, if you take responsibility for double- checking a colleagues mathematical calculations, be certain that you perform the calculation yourself. The most widely accepted procedure for correcting errors has been to draw a single line through error and note mistaken entry, error, or the error notation that is required by your facility, followed by the date and your initials. Since your signature follows the original entry, your initials are sufficient unless facility policy requires otherwise. Never erase an entry or use correction fluid, liquid paper, or white out. If you need to replace several words, you may need to add an addendum sheet and follow the procedure for late entries. Document the time of your entry. Within the body of your note indicate the time of the occurrence to which you are referring. Do your best to avoid late entries since they raise suspicion. However, entering pertinent information is better done late than never. Shorter lengths of stay on inpatient units increase the likelihood of the need for late entries. Stick strictly to the facts and include no assumptions about what you think probably occurred or contributed to the event. Include: Your observations of the event. Your specific interventions with the patient and the patients response. Any statements by the patient concerning the event. Be sure to identify in quotation marks as patient statements, making it clear that this is the patients description and not your observation. Any change in the medical or nursing care plan because of this event, including changes in monitoring or medications. Full names of personnel you notified of the event. Do not indicate that you completed an incident report or notified the risk management department. Leave no blank spaces in your notes. If you are starting a new page, be certain there are no blanks on the page before. Use the appropriate form and document in ink. Verify that the correct patients name and ID number are on every page of the chart. Record the complete date and time of each entry. Use only standard, facility-approved abbreviations, acronyms and symbols. Use a medical term only if you are sure of its meaning. Document symptoms by using the patients own words. Document objectively. Write legibly. Locate and orient yourself to all interdisciplinary forms, progress notes and flow sheets. If you replace a page on which information has been recorded, retain the original and place it in the medical record according to policy. Write on every line. Sign your full name and title. Chart any omission or late entry as a new entry. Do not backdate or add to previously written notes. THANK YOU FOR LISTENING... All ED nurses need to be especially conscientious about communication and documentation. It is especially critical that you familiarize yourself with ED policies and procedures and follow them faithfully.