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64 Cards in this Set
- Front
- Back
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give two main documentation systems
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source oriented records and problem oriented records
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essential components of clients records / chart - Source Oriented Records
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admission data, advance directive, HX/physical, physicians orders, progress notes, diagnostic studies, labs, rehab/therapy notes, graphic data, nurses notes, discharge planning
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essential components of
clients records / chart -Problem Oriented Records |
database, problem list, plan of care, progress notes
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intake and output records, vitals, pt activity, dietary intake, ADL task are listed under __ in the SOR
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graphic data
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chronological charting by physicians on pts response to treatment is listed under ___ in the SOR
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progress notes
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chronological charting by nurses on pts response to treatment is listed under __ in the SOR
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nurses notes
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admission data in the SOR can include
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demographic info, insurance data, contact information
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in problem oriented records POR) what information is provided in the database
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demographic, hx/physical, nursing assess., pertinent fam. and social hist., pts condition chgs -reflects pt current status
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in POR, a consise list of problems can be fd in
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the problem list, once problem resolved it resolved, its noted on list,,if prob chgs its updated
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in POR the plan of care includes
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physicians orders, nursing care plan for addressing identified problems
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In POR organized acc/to problem list, each discipline charts on shared notes, charting labeled acc/to problem number
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progess notes
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what is the purpose of the clients healthcare record
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written record serves for: communication, education, legal documentation, quality assurance, reimbursement, research
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purpose & contents of
change-of-shift report |
alert nxt caregiver about client status, recent chgs, planned activities, tests, procedures, concerns that require follow up
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Key points to incl in shift reports (CUBAN)
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C-confiential, private loc.
U-uninterrupted,is focused/ less time consuming B-brief,consise/centered on pt A-accurate,pertinent /important info N-named nurse, who delivered care |
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begin to use correct medical terminology by
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-avoid, good, avg, normal
-proper sp./grammar -use appvd abbrv per facility |
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how to chart
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accurate, concise, complete, specific, timely
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what to chart
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-basic assessment data
-any abnormalities in depth -nursing actions taken -pt response to actions -progress toward goals of plan of care -education provide to pt -discharge needs/care/instruc. |
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the "DOs" of charting
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-verify pt name correct
-current date on chart -write legibly, blk ink, correct spelling, proper terms/grammar -after entry draw horiz line thru addl line space and sign @ end -use hosp apprvd abbrev |
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-dont leave pt data displayed
-nvr remove pt info fr facilty -dispose confidential papers properly |
ways to maintain confidentiality of records and reports
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-access records on a "need to know" basis only
-never share passwords -dont leave pc unattended |
ways to maintain confidentiality of records and reports
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documenting relevant data in retrievable format, doc diag/issues to aid in determining expected outcome
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by ANA standard the rn
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use standardized language or recognized terminology to doc care plan, doc implementation, any modifications, incl chgs of omissions of identified plan
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characteristics of proper documentation
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doc results of evaluation, collaborate in creating a doc plan focused on outcomes, doc referrals incl provisions for continuity of care
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characteristics of proper documentation
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legal guidelines for documentation
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any charting format that adequately describes patients condition,care given & response to care is adequate & will w/stand review in court of law
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-doc potential seriour sit.
-record fact & specific times -incl objective observations -report to physician/spvr -doc all actions taken -add quotes/paraphrase specific communication |
the "DOs" of charting
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-communication re:pt status/care
-legal record of care |
purpose of documentation
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advantages of narrative charting
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easy to learn
easy to adjust can explain in detail |
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disadvantages of narrative charting
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time consuming
difficult to retrieve info irrelevant info often incl possibly unfocused/disorganzd |
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used w/both SOR & POR charts, tells story of pts experience in chronological format, good use of timeline
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narrative charting
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block charting is
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-doc in paragraph form everything in shift @ end of shift
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focuses on important aspect of care but can easily omit important info
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block charting
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inadequate when describing events that require timing, prefer charting done more freq(eg care of unstable pt)
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block charting
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if not charted
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it didnt happen, hosp/phys not paid - no reimbursment
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aka pt care summary, brief summary of pts plan of care, usually all pts kept together,not part of permanent record
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Kardex
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includes pts meds, incl allergies,PRN (as needed), STAT (immediately)
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MAR -medication administration record
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addl info often needed to be added to MAR
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injection site,assessment req before admin, new allergic rxns not listed, time PRN given w/brief narrative assess, pt refusal, omitted/delayed meds
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the "DONTs" of charting
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-share passwords w/anyone
-correct mistaken entry, by erasing, white out, crossing it out (X), or scribbling |
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-use negative language, incl inappropriate info in pt record
-use labels to descr pt |
the "DONTs" of charting
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-record staff problems, staff conflicts
-mention incident reports -use words assoc w/errors |
the "DONTs" of charting
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-chart casual conversation w/co-workers
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the "DONTs" of charting
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charting principles
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-How/What/When to chart
-What not to chart -Who should chart |
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SOAP
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Subjective data
Objective data Assessment Plan |
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SOAPIER
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Subjective data
Objective data Assessment Plan Interventions Evaluation Revision |
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the WHEN to charting
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doc in timely manner-when you perform it or shortly after AND never doc ahead
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the WHO to charting
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chart what you see/do, never ask someone else to cahrt for you, never complete someone elses charting
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methods of report
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face-to-face, tape recorded, phone, computer printout, written
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soap advantages
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all charting focused around clt problem,interdisciplinary,
everyone charts on same notes, easy to track progress |
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soap disadvantages
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difficult to master, specific focus-difficult to chart general info w/o identifying problem,lengthy/time consuming
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PIE advantages
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plan of care incorporated in progress notes, outcomes incl, daily review to determine progress, less redundancy, easily adaptable to automated charting
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PIE disadvantages
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must read progress notes to determine plan of care, if problem not ID'd-difficult to chart, not multidisciplinary
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FOCUS/DAR
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Data
Action Response |
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advantages of FOCUS/DAR
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broad view-can chart on any significant area, concise, flexible,works well in LTC- ambulatory care-mental health
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disadvantages of FOCUS/DAR
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not multidisciplinary, difficult to identify chronological order, progress note may not relate to plan of care
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charting by exception CBE
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charting system designed to streamline documentation
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advantages of CBE
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efficient, use of flow sheets permit rapid detection of changes, can take place of care plan
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disadvantages of CBE
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expensive to institute-must in-service staff, not prevention focused, not appropriate for long-term or ambulatory care
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CBE examples
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client refuses medication, lung sounds are abnormal, clients oxygenation status is deteriorating
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charting difficulties - error corrections
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draw single line thru it, write "mistaken entry", ititial, date and time
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if chart unavailable
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add info on 1st available line, start w/current date & time, write "last entry" & reason, document care indicating time care occured, sign entry
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Incident reports
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completed by staff who witnessed or found the incident, not included in your notes, internal records only (not discoverable)
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verbal orders - in person
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doctor should write order on chart, repear order back to doctor, ask for any clarification immediately
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verbal order - over telephone
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repeat order back to doctor, doc should sign off when on unit (w/in 24hrs)
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Legal issues- know what order to question
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any order a pt questions, any order if pts conditions has changed, standing orders if inexperienced & have questions, ambiguous order, you can clarify/discuss an order w/your supervisor
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nursing documentation
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progess ntoes, flow-sheets, education record, mar, i/o sheets, vs graphic (vital signs info), computer charting
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