The document discusses various uses and guidelines for medical record documentation. It covers tracking patient progress, sharing information between providers, maintaining patient confidentiality, ensuring quality of care through audits, meeting requirements for insurance reimbursement, using records for research, and providing legal evidence. Key aspects that must be documented include assessments, nursing diagnoses, interventions, patient responses and outcomes. The document also reviews different charting styles like SOAP and problem-oriented documentation.

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 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

8. 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

9. 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.

10. 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.

11. 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.

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

13. 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.

14. 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.

15. TYPES OF PATIENT RECORDS SOURCE-ORIENTED PROBLEM-ORIENTED

16. 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.

17. 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.

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

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

20. 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.

21. 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

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

23. 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.”

24. 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

25. 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.

26. 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

27. 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.

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

29. 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.

30. CHANGE OF SHIFT REPORT PERSON TO PERSON BE PREPARED AVOID GOSSIP/SOCIALIZATION TAPE RECORDER

31. 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”

32. 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.