Nursing hi nursing

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
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

8. 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.

9. 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.

10. 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.

11. ACCESS TO CHARTS
PATIENT’S RIGHTS
WHO OWNS
CHART
AGENCY POLICY

12. 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.

13. 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.

14. TYPES OF PATIENT RECORDS
 SOURCE-ORIENTED
 PROBLEM-ORIENTED

15. 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.

16. 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.

17. METHODS (STYLES) OF CHARTING
 NARRATIVE
 SOAP
SOAPIER
 FOCUS
DATA
ACTION
RESPONSE
 PIE
 EXCEPTION CHARTING

18. NARRATIVE
CHRONOLOGICAL
BASELINE CHARTED QSHIFT
LENGTHY, TIME-CONSUMING
SEPARATE PAGES FOR EACH
SOURCE-ORIENTED

19. 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.

20. 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

21. FOCUS CHARTING
USES NARRATIVE DOCUMENTATION
(DAR)
 DATA – SUBJECTIVE OR OBJECTIVE THAT
SUPPORTS THE FOCUS (CONCERN)
 ACTION – NURSING INTERVENTION
 RESPONSE – PT RESPONSE TO INTERVENTION

22. 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.”

23. 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

24. 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.

25. 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

26. 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.

27. KARDEX
QUICK REFERENCE
CHANGED AS NEEDED
NOT PART OF PERMANENT RECORD

28. 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.

29. CHANGE OF SHIFT REPORT
PERSON TO
PERSON
BE PREPARED
AVOID
GOSSIP/SOCIALIZA
TION
TAPE RECORDER

30. 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”

31. 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.