CHARTING

Charting

The process of recording patient care and observations in a health care record.

Health Care Record

A systematic collection of a patient's health information.

Documentation

The act of formally recording information related to patient care.

Legal Documentation

Documentation that is legally defensible and meets regulatory standards.

Nursing Progress Notes

Records that document a patient's progress in response to nursing interventions.

End of Shift Report

A report given at the end of a shift to relay patient information for continuity of care.

Mistaken Entry

An entry that needs to be corrected by drawing a line through it and labeling it as mistaken.

SOAP Charting

A method of documentation that includes Subjective, Objective, Assessment, and Plan.

Charting DOs

Guidelines for proper documentation practices, including accuracy and legibility.

Charting DON’Ts

Common mistakes to avoid in documentation, such as backdating or altering entries.

SBAR Method

A communication framework that stands for Situation, Background, Assessment, and Recommendation.

Patient Outcomes

The results or changes in a patient's health status following care provided.

Adverse Event

An unexpected and undesirable occurrence associated with the provision of care.

Chain of Command Issues

Concerns related to the hierarchy or order of authority in a healthcare setting.

Focus Charting

A documentation method that emphasizes patient-centered care, using the acronym for Subject, Data, Action, Response.

Audit

A systematic review of documentation for accuracy and compliance with standards.

Confidentiality

The ethical principle of keeping patient information private.

Clinical Guidelines

Recommendations designed to streamline decisions in health care.