Nursing Skills: Charting

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

PERMANENT RECORD
WRITTEN IN CHRONOLOGICAL ORDER
FILED IN MEDICAL RECORDS DEPT FOR FUTURE USE/REFERENCE

SHARING INFORMATION
FACILITATES EXCHANGE OF INFORMATION BETWEEN STAFF
PREVENTS DUPLICATION ERRORS
(MEDS, DRESSING CHANGE, ACTIVITY, DIETS, ETC.)

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.

QUALITY ASSURANCE
A PEER REVIEW PROCESS CONDUCTED BY A STAFF NURSE AND PHYSICIAN
ESTABLISHES AND REFLECTS AGENCY STANDARDS

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

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

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.

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.

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

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.

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.

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Nursing Skills: Charting

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