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.
B. PIE CHARTING
Similar to SOAP charting
Both are problem-oriented
PIE comes from the Nursing Process, SOAP comes from a Medical Model.
P - Problem
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
C. FOCUS CHARTING
USES NARRATIVE DOCUMENTATION (DAR)
DATA – SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE FOCUS (CONCERN)
ACTION – NURSING INTERVENTION
RESPONSE – PT RESPONSE TO INTERVENTION
D – COMPLAINING OF PAIN AT INCISION SITE , PS: 7/10
A – REPOSITIONED FOR COMFORT. DEMEROL 50MG IM GIVEN.
R – STATES A DECREASE IN PAIN, “FEELS MUCH BETTER.”
D. COMPUTERIZED CHARTING
PASSWORD. NEVER SHARE. CHANGE FREQUENTLY.
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.
Provides a concise method of organizing and recording data about a client, making information readily accessible to all members of the health team
It is a series of flip cards usually kept in portable file
It is a way to ensure continuity of care from one shift to another and from one day to the next
It is a tool for change – of – shift report. But endorsement is not simply reciting content of kardex. Health care needs of the client is still primary basis for endoresement.
Usually include the ff. data:
Daily nursing procedures
Medications and intravenous (IV) therapy, blood transfusions
Treatments like oxygen therapy, steam inhalation, suctioning, change of dressings, mechanical ventilation.
Entries usually written in pencil. This implies the kardex is for planning ang communication purpose only.
GENERAL DOCUMENTATION GUIDELINES
Ensure that you have the correct client record or chart.
Document as soon as the client encounter is concluded to ensure accurate recall of data.
Date and time of each entry.
Sign each entry with your full legal name and with your professional credentials.
Do not leave space in between entries.
If an error is made while documenting, use a single line to cross out the error, then date, time and sign the correction
Never change another person’s entry even if it is incorrect
Use quotation marks to indicate direct client responses.
Document in chronological order
Use permanent ink
Document all telephone calls that you received that are related to client’s case.
Characteristic of Good Recording:
Entries are concise
Complete sentences are not required
Start each entry with a capital letter and end the entry with a period even if the entry is a single word or phrase.
Avoid pencil for permanence of data, because the client’s chart can be used as an evidence in a legal court.
Chart objective facts, not your interpretations or opinions
Ate 50% of the food served.
Ate with poor appetite.
Place complaint of the client in quotation marks to indicate that it is his statement.
“ chest pain radiating down the left arm”
“ nahihirapan akong huminga kapag nakahiga”
Objective data are also to be charted.
E.g. skin cold and clammy. Diaphoretic. Prefers to sit up. Vital signs taken as follows: temp-37.6C, PR-110/min., RR-26/min. BP-140/90 mmHg.
Describe behaviors rather than feelings to allow other health team members to determine the actual problems of the client.
Refusal of medications and treatments must be documented.
Only information that pertains to the client’s health problems and care are recorded.
Any other personal information that is conveyed to the nurse is appropriate for the record.
Completeness and chronology/organization/sequence/timing.
Notes should appear on each succeeding line
Continuous charting is done for each entry unless a time change occurs. No need for a new line for each new idea or entry.
Date is entered in the date column on the first line of every page of nurse’s notes and whenever the date changes.
Time is entered in the time column whenever a new time entry occurs.
Avoid time changes in the text of nurse’s notes.
Avoid double chart. If something appears on a particular sheet, it does not need to appear on the nurse’s notes, unless there is an alternation from the normal, e.g. body temperature, blood pressure.
Avoid squeezing information to a space because you forgot to chart it earlier. Add the information on the first available line. Write the time the event occurred, not the time you entered the information.
The following information should be charted:
Times the patient leaves and returns to the unit, mode of transportation and destination.
Medications should be charted immediately after administration.
Treatments should be charted immediately after being done.
Use of standard terminology
Use only those abbreviations and symbols approved by the institution; spell correctly; use proper grammar.
Affix signature, place at the end of charting, at the right hand margin of the nurse’s notes.
Sign each entry with your full name and status, e.g. SN for Student Nurse, RN for registered nurse.
Script, not printing is used for the signature.
In case of error.
Correct errors by drawing a single horizontal line
through the error
Write the word error above the line, then sign
No ink eradication, erasures or use of occlusive materials.
Only the health personnel who participate in the care of the client are allowed to read the chart.
Chart only what you personally have done, observe, heard, smelled, or felt.
Do not discard any of the client record.
Writing must be clear and easily read by others
If writing is not legible, then print.
A horizontal line drawn to fill up a partial line. This is to prevent other persons from adding information in the nurse’s notes.
Needs attended. Referred accordingly.-------Ma. Tosca Cybil Torres, RN, MAN
takes place when two or more people share information about client care , either face to face or by telephone.
Types of reporting
change – of – shift reports or endorsement
for continuity of care
it is based on health care needs of the client
it is not mere reciting the content of the kardex
provide clear accurate and concise information
the nurse documents telephone report by including the following information:
when the call was made
who made the call/report
who was called
to whom information was given
what information was given
what information was received
Only RN’s may receive telephone orders
The order need to be verified by reporting it clearly and precisely.
The order should be countersigned by the physician who made the order within the prescribed period of time (within 24 hours)
this is done when transferring a client from unit to another.
Incident Reports or occurrence reports
Used to document any unusual occurrence or accident in the delivery of client care
Antonio, a 55 y/o farmer, was found by his son lying on the floor unconscious. He was brought to the ER and was diagnosed with CVA, probably bleed. He is then admitted to the medical ICU for continuity of critical care. He is drowsy, restless at times, severely dyspneic, and with excessive secretions. Crackles are heard upon auscultation at both lower lung fields. V/S: BP 190/110mmHg, T° 39°C, RR 38cpm, PR 112bpm