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Nursing Skills: Charting

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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.

Published in: Health & Medicine, Business

Nursing Skills: Charting

  1. 1. CHARTING
  2. 2. USES FOR THE MEDICAL RECORD <ul><li>PERMANENT ACCOUNT </li></ul><ul><li>TRACKS PT PROGRESS/CARE GIVEN </li></ul><ul><li>SHARING INFORMATION </li></ul><ul><li>PATIENT CONFIDENTIALITY </li></ul><ul><li>QUALITY ASSURANCE </li></ul><ul><li>ACCREDITATION </li></ul><ul><li>6 ITEMS THAT MUST BE DOCUMENTED </li></ul><ul><li>INSURANCE REIMBURSEMENT </li></ul><ul><li>RESEARCH </li></ul><ul><li>LEGAL EVIDENCE FOR MALPRACTICE SUITS </li></ul><ul><li>ASSURES CONTINUITY OF CARE </li></ul>
  3. 3. USES FOR THE MEDICAL RECORD <ul><li>PERMANENT RECORD </li></ul><ul><li>WRITTEN IN CHRONOLOGICAL ORDER </li></ul><ul><li>FILED IN MEDICAL RECORDS DEPT FOR FUTURE USE/REFERENCE </li></ul>
  4. 4. USES FOR THE MEDICAL RECORD <ul><li>SHARING INFORMATION </li></ul><ul><li>FACILITATES EXCHANGE OF INFORMATION BETWEEN STAFF </li></ul><ul><li>PREVENTS DUPLICATION ERRORS </li></ul><ul><li>(MEDS, DRESSING CHANGE, ACTIVITY, DIETS, ETC.) </li></ul>
  5. 5. USES FOR THE MEDICAL RECORD <ul><li>PATIENT CONFIDENTIALITY </li></ul><ul><li>NEVER LEAVE CHART IN A PUBLIC PLACE. </li></ul><ul><li>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. </li></ul><ul><li>ASK FOR ID PRIOR. </li></ul><ul><li>DO NOT DISCUSS PT OR PT INFO IN PUBLIC PLACES, EG. ELEVATORS, CAFTERIA. </li></ul>
  6. 6. USES FOR THE MEDICAL RECORD <ul><li>QUALITY ASSURANCE </li></ul><ul><li>A PEER REVIEW PROCESS CONDUCTED BY A STAFF NURSE AND PHYSICIAN </li></ul><ul><li>ESTABLISHES AND REFLECTS AGENCY STANDARDS </li></ul>
  7. 7. USES FOR THE MEDICAL RECORD <ul><li>ACCREDITATION </li></ul><ul><li>JCAHO (JOINT COMMISSION ON ACCREDITATION OF HEALTH ORGANIZATION)/DSHS STATE (EXTENDED CARE) </li></ul><ul><li>SETS MINIMUM STANDARDS FOR STAFFING </li></ul><ul><li>THE AMERICAN NURSE’S ASSOCIATION SETS THE STANDARDS FOR PT CARE & DOCUMENTATION FOR NURSE’S </li></ul>
  8. 8. USES FOR THE MEDICAL RECORD <ul><li>SIX ITEMS THAT NURSES MUST DOCUMENT </li></ul><ul><li>ASSESSMENT </li></ul><ul><li>NURSG DX AND PT NEEDS </li></ul><ul><li>INTERVENTIONS </li></ul><ul><li>CARE PROVIDED </li></ul><ul><li>PT RESPONSE TO CARE </li></ul><ul><li>PTS ABILITY TO MANAGE CONTINUING CARE AFTER DISCHARGE </li></ul>
  9. 9. USES FOR THE MEDICAL RECORD <ul><li>REIMBURSEMENT </li></ul><ul><li>LACK OF DOCUMENTATION MAY RESULT IN DENIAL FOR PAYMENTS FROM MEDICARE AND PRIVATE INSURANCE COMPANIES. THIS PUTS THE BURDEN OF PAYMENT ON THE PATIENT. </li></ul>
  10. 10. USES FOR THE MEDICAL RECORD <ul><li>RESEARCH </li></ul><ul><li>DATA ON TREATMENTS, MEDS, AND THERAPY </li></ul><ul><li>INFO FOR TUMOR BOARDS, DOCTOR’S ROUNDS, NURSING ROUNDS, ETC. </li></ul><ul><li>BE AWARE OF PRIVACY ISSUES </li></ul><ul><li>NURSES, STUDENT NURSES USE FOR CARE PLANS. </li></ul>
  11. 11. USES FOR THE MEDICAL RECORD <ul><li>LEGAL EVIDENCE </li></ul><ul><li>RECORDS ARE CONSIDERED LEGAL OR POTENTIAL LEGAL DOCUMENTS </li></ul><ul><li>MAY BE SUBPEONAED AS EVIDENCE BY ATTORNEY OR NURSING BOARDS. CHECK FOR DEVIATIONS FROM FACILITY POLICY OR STANDARDS. </li></ul><ul><li>EACH HEALTH CARE PROVIDER IS RESPONSIBLE FOR THE ABC’S OF RECORDING. ACCURACY, BRIEF, COMPLETE. </li></ul>
  12. 12. ACCESS TO CHARTS <ul><li>PATIENT’S RIGHTS </li></ul><ul><li>WHO OWNS CHART </li></ul><ul><li>AGENCY POLICY </li></ul>
  13. 13. ACCESS TO CHARTS <ul><li>PATIENT’S RIGHTS/AGENCY POLICY </li></ul><ul><li>PATIENTS HAVE THE RIGHT TO THE INFO IN THEIR CHARTS. </li></ul><ul><li>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. </li></ul>
  14. 14. ACCESS TO CHARTS <ul><li>WHO OWNS THE CHART </li></ul><ul><li>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. </li></ul>
  15. 15. TYPES OF PATIENT RECORDS <ul><li>SOURCE-ORIENTED </li></ul><ul><li>PROBLEM-ORIENTED </li></ul>
  16. 16. TYPES OF PATIENT RECORDS <ul><li>SOURCE ORIENTED </li></ul><ul><li>MOST TRADITIONAL </li></ul><ul><li>DIFFERENT DISCIPLINES CHART ON SEPARATE FORMS. </li></ul><ul><li>EACH READER MUST CONSULT VARIOUS PARTS OF THE RECORD TO GET A COMPLETE PICTURE. </li></ul><ul><li>RECORDS BECOMES BULKY. </li></ul>
  17. 17. TYPES OF PATIENT RECORDS <ul><li>PROBLEM ORIENTED </li></ul><ul><li>COMMONLY REFERRED TO AS POR. </li></ul><ul><li>ORGANIZED ACCORDING TO PROBLEM. </li></ul><ul><li>FOUR PARTS: </li></ul><ul><li>A. DATA BASE. THE PATIENTS PRESENT HEALTH STATUS. </li></ul><ul><li>B. PROBLEM LIST. NUMBERED LIST OF HEALTH PROBLEMS. </li></ul><ul><li>C. INITIAL PLAN. PLAN TO HELP OVERCOME HEALTH PROBLEMS. </li></ul><ul><li>D. PROGRESS NOTES. ALL DISCIPLINES CHART ON SAME PAGE. </li></ul>
  18. 18. METHODS (STYLES) OF CHARTING <ul><li>NARRATIVE </li></ul><ul><li>SOAP </li></ul><ul><li>SOAPIER </li></ul><ul><li>FOCUS </li></ul><ul><li>DATA </li></ul><ul><li>ACTION </li></ul><ul><li>RESPONSE </li></ul><ul><li>PIE </li></ul><ul><li>EXCEPTION CHARTING </li></ul>
  19. 19. NARRATIVE <ul><li>CHRONOLOGICAL </li></ul><ul><li>BASELINE CHARTED QSHIFT </li></ul><ul><li>LENGTHY, TIME-CONSUMING </li></ul><ul><li>SEPARATE PAGES FOR EACH </li></ul><ul><li>SOURCE-ORIENTED </li></ul>
  20. 20. SOAP <ul><li>USED FOR PROBLEM-ORIENTED CHARTS </li></ul><ul><li>S – SUBJECTIVE. WHAT PT TELLS YOU. </li></ul><ul><li>0 – OBJECTIVE. WHAT YOU OBSERVE, SEE. </li></ul><ul><li>A – ASSESSMENT. WHAT YOU THINK IS GOING ON BASED ON YOUR DATA. </li></ul><ul><li>P – PLAN. WHAT YOU ARE GOING TO DO. </li></ul><ul><li>CAN ADD TO BETTER REFLECT NURSING PROCESS </li></ul><ul><li>I – INTERVENTION (SPECIFIC INTERVENTIONS IMPLEMENTED) </li></ul><ul><li>E – EVALUATION. PT RESPONSE TO INTERVENTIONS. </li></ul><ul><li>R – REVISION. CHANGES IN TREATMENT. </li></ul>
  21. 21. EXAMPLE OF SOAP CHARTING <ul><li>#1 ALTERATION IN COMFORT. ABDOMINAL PAIN. </li></ul><ul><li>S – COMPLAINS OF PAIN IN RUQ </li></ul><ul><li>O – IS PALE AND HOLDING RIGHT SIDE </li></ul><ul><li>A – RECURRING ABDOMINAL PAIN </li></ul><ul><li>P – PUT ON NPO AND NOTIFY PHYSICIAN </li></ul>
  22. 22. FOCUS CHARTING <ul><li>USES NARRATIVE DOCUMENTATION (DAR) </li></ul><ul><li>DATA – SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE FOCUS (CONCERN) </li></ul><ul><li>ACTION – NURSING INTERVENTION </li></ul><ul><li>RESPONSE – PT RESPONSE TO INTERVENTION </li></ul>
  23. 23. EXAMPLE OF FOCUS CHARTING <ul><li>D – COMPLAINING OF PAIN AT INCISION SITE ON LEVEL OF #7 </li></ul><ul><li>A – REPOSITIONED FOR COMFORT. DEMEROL 50MG IM GIVEN. </li></ul><ul><li>R – (CHARTED AT A LATER DATE.) STATES A DECREASE IN PAIN, “FEELS MUCH BETTER.” </li></ul>
  24. 24. PIE CHARTING <ul><li>Similar to SOAP charting </li></ul><ul><li>Both are problem-oriented </li></ul><ul><li>PIE comes from the Nursing Process, SOAP comes from a Medical Model. </li></ul><ul><li>P - Problem </li></ul><ul><li>I -Intervention </li></ul><ul><li>E -Evaluation </li></ul>
  25. 25. SAMPLE OF PIE CHARTING <ul><li>P#1 Risk for trauma related to dizziness. </li></ul><ul><li>IP#1 Instructed to call for assistance when </li></ul><ul><li>getting OOB. Call light in reach. </li></ul><ul><li>EP#1 Consistently call for assistance </li></ul><ul><li>before getting OOB. Continues to </li></ul><ul><li>experience dizziness. </li></ul>
  26. 26. CHARTING BY EXCEPTION <ul><li>USES FLOWSHEETS </li></ul><ul><li>EMPHASIS ON ABNORMAL (WHAT IS ABNORMAL FOR THIS PATIENT. </li></ul><ul><li>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”. </li></ul><ul><li>ADVANTAGE </li></ul>
  27. 27. COMPUTERIZED CHARTING <ul><li>PASSWORD. NEVER SHARE. CHANGE FREQUENTLY. </li></ul><ul><li>LEGIBLE </li></ul><ul><li>CAN BE VOICE-ACTIVATED, TOUCH-ACTIVATED. </li></ul><ul><li>DATE AND TIME AUTOMATICALLY RECORDED. </li></ul><ul><li>ABBREVIATIONS AND TERMS ARE SELECTED BY A MENU PROVIDED BY THE FACILITY. </li></ul><ul><li>TERMINALS ARE USUALLY EASILY ACCESSIBLE, IN PT ROOMS, CONVENIENT HALLWAY LOCATIONS. </li></ul><ul><li>MAKE SURE TERMINAL CANNOT BE VIEWED BY UNAUTHORIZED PERSONS. </li></ul>
  28. 28. KARDEX <ul><li>QUICK REFERENCE </li></ul><ul><li>CHANGED AS NEEDED </li></ul><ul><li>NOT PART OF PERMANENT RECORD </li></ul>
  29. 29. ABBREVIATIONS <ul><li>YOU MUST USE YOUR FACILITY’S APPROVED ABBREVIATIONS. </li></ul><ul><li>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. </li></ul>
  30. 30. CHANGE OF SHIFT REPORT <ul><li>PERSON TO PERSON </li></ul><ul><li>BE PREPARED </li></ul><ul><li>AVOID GOSSIP/SOCIALIZATION </li></ul><ul><li>TAPE RECORDER </li></ul>
  31. 31. INCIDENT REPORTS <ul><li>OBJECTIVE </li></ul><ul><li>DO NOT BLAME OR ADMIT LIABILITY </li></ul><ul><li>WHAT DID YOU DO? </li></ul><ul><li>DO NOT INCLUDE NAMES/ADDRESSES OF WITNESSES </li></ul><ul><li>DOCUMENT TIME/NAME OF DOCTOR </li></ul><ul><li>DO NOT FILE IN CHART </li></ul><ul><li>DO NOT WRITE “INCIDENT REPORT MADE” </li></ul>
  32. 32. CORRECTING ERRORS <ul><li>IF YOU SPILL SOMETHING ON THE CHART, DO NOT DISCARD NOTES. RECOPY, PUT ORIGINAL AND COPIED SHEETS IN CHART. WRITE “COPIED” ON COPY. </li></ul><ul><li>DO NOT SCRIBBLE OUT CHARTING. </li></ul><ul><li>AVOID USING “ERROR” OR “WRONG PATIENT” WHEN MAKING CORRECTION. </li></ul><ul><li>FOLLOW YOUR FACILITIES POLICY. </li></ul><ul><li>DO NOT ALTER CHARTING, IT IS A LEGAL DOCUMENT. </li></ul>

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