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Nursing Skills: Charting

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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…

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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
- ASSESSMENT
- NURSG DX AND PT NEEDS
- INTERVENTIONS
- CARE 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
- 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.
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 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.
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.
METHODS (STYLES) OF CHARTING
- NARRATIVE
- SOAP
- SOAPIER
- FOCUS
- DATA
- ACTION
- RESPONSE
- PIE
- EXCEPTION CHARTING
NARRATIVE
- CHRONOLOGICAL
- BASELINE CHARTED QSHIFT
- LENGTHY, TIME-CONSUMING
- SEPARATE PAGES FOR EACH
- SOURCE-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 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
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 PREPARED
- AVOID 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.