nursing skills: charting
DESCRIPTION
For those of you who want to get a head start on the chartsmart, these are the applicable slides. Also, Brenda has a sheet of "Descriptive Terms" that you will want for that project. She handed it out to a few people the other day who wanted to get a head start on the charting assignment.TRANSCRIPT
CHARTING
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
USES FOR THE MEDICAL RECORD
PERMANENT RECORD
WRITTEN IN CHRONOLOGICAL ORDER
FILED IN MEDICAL RECORDS DEPT FOR FUTURE USE/REFERENCE
USES FOR THE MEDICAL RECORD
SHARING INFORMATION
FACILITATES EXCHANGE OF INFORMATION BETWEEN STAFF
PREVENTS DUPLICATION ERRORS (MEDS, DRESSING CHANGE, ACTIVITY, DIETS, ETC.)
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.
USES FOR THE MEDICAL RECORD
QUALITY ASSURANCE
A PEER REVIEW PROCESS CONDUCTED BY A STAFF NURSE AND PHYSICIAN
ESTABLISHES AND REFLECTS AGENCY STANDARDS
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
USES FOR THE MEDICAL RECORD
SIX ITEMS THAT NURSES MUST DOCUMENT
ASSESSMENTNURSG DX AND PT NEEDS INTERVENTIONSCARE PROVIDED PT RESPONSE TO CARE PTS ABILITY TO MANAGE CONTINUING
CARE AFTER DISCHARGE
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.
USES FOR THE MEDICAL RECORD
RESEARCHDATA ON TREATMENTS, MEDS, AND
THERAPY INFO FOR TUMOR BOARDS, DOCTOR’S
ROUNDS, NURSING ROUNDS, ETC.BE AWARE OF PRIVACY ISSUESNURSES, STUDENT NURSES USE FOR
CARE PLANS.
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.
ACCESS TO CHARTS
PATIENT’S RIGHTS
WHO OWNS CHART
AGENCY POLICY
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.
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.
TYPES OF PATIENT RECORDS
SOURCE-ORIENTED
PROBLEM-ORIENTED
TYPES OF PATIENT RECORDS
SOURCE ORIENTEDMOST TRADITIONALDIFFERENT DISCIPLINES CHART ON
SEPARATE FORMS.EACH READER MUST CONSULT
VARIOUS PARTS OF THE RECORD TO GET A COMPLETE PICTURE.
RECORDS BECOMES BULKY.
TYPES OF PATIENT RECORDS
PROBLEM ORIENTEDCOMMONLY 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.
METHODS (STYLES) OF CHARTING
NARRATIVE SOAP
SOAPIER FOCUS
DATA
ACTION
RESPONSE PIE EXCEPTION CHARTING
NARRATIVECHRONOLOGICALBASELINE CHARTED QSHIFT
LENGTHY, TIME-CONSUMING
SEPARATE PAGES FOR EACHSOURCE-ORIENTED
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.
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
FOCUS CHARTING
USES NARRATIVE DOCUMENTATION (DAR)
DATA – SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE FOCUS (CONCERN)
ACTION – NURSING INTERVENTION
RESPONSE – PT RESPONSE TO INTERVENTION
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.”
PIE CHARTINGSimilar to SOAP chartingBoth are problem-orientedPIE comes from the Nursing Process,
SOAP comes from a Medical Model.P-ProblemI-InterventionE-Evaluation
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.
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
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.
KARDEX
QUICK REFERENCE
CHANGED AS NEEDED
NOT PART OF PERMANENT RECORD
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.
CHANGE OF SHIFT REPORT
PERSON TO PERSON
BE PREPAREDAVOID
GOSSIP/SOCIALIZATION
TAPE RECORDER
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”
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.