Charting & Group Dynamic

Charting rules:

  • BEGIN EACH CHARTING NOTE WITH DATE & TIME

  • USE 24 HR CLOCK

  • IDENTIFY YOUR DISCIPLINE

  • INCLUDE DATE &TIME OF EACH SEPARATE ENTRY

  • SIGN YOUR NAME OFF AS SUCH: T. Jones S.N Dawson College

  • CHART THROUGHOUT YOUR SHIFT

  • USE COMMONLY APPROVED ABBREVIATIONS (PRN)

  • USE APPROPRIATE SPELLING (Tylenol)

  • NO SPECULATIONS ONLY FACTS

  • QUOTE PATIENT OR FAMILY STATEMENTS

  • AVOID PERSONAL OPINION

  • RESPECT SPACING IN CHARTING

  • WRITE ACTUAL TIME YOU ARE CHARTING LATE ENTRY

  • WRITE TIME AND DATE OF LATE ENTRY EVENT

  • DOCUMENT EVENTS IN CHRONOLOGICAL ORDER IN WHICH THEY OCCUR


Do not:

**“PRE-CHART”

**RECORD THAT AN “ERROR” WAS MADE BY A PHYSICIAN ON THEIR PHYSICIAN'S ORDER

**NEVER DOCUMENT FOR OTHERS

**USE GENERALIZED STATEMENT

**USE “WHITE-OUT” OR SCRATCH OUT ERRORS MADE WHILE RECORDING


Computerized charting:

  • DONT SHARE YOUR PASSWORD

  • LOG OUT BEFORE WALKING OUT

  • CLOSE PT INFO FROM SCREEN

  • SHRED DOCUMENTS

  • KNOW YOUR FACILITY DOCUMENTATION REGULATIONS


CHARTING BY EXEPTION (CBE)

Shorthand method for documenting normal findings (using flowsheets)

Based on:

  • Defined standards of practice

  • Pre-determined criteria for nursing assessments and interventions.

  • Only significant findings or exceptions to the norm are documented

  • Checkmark is used if all normal

  • Nursing documentation time is cut significantly.

  • Abnormal findings are highlighted.

  • Documentation of routine care is eliminated through the use of nursing standards.

  • Patient data is written when collected.

  • Assessments are standardized.

  • No duplication of information.


PROBLEM FOCUSED (DARP)

According to patient concern (the focus). Written in progress notes.

Focus:

  • Sign, symptom or a condition

  • Patient behaviour

  • Significant event/change in the patient’s condition.

  • Follows the nursing process.


DATA

Subjective & objective data that relates to focus

ACTION

Action that nurse takes in response to her analysis of the data (nursing intervention)

RESPONSE

Client’s response to the nursing intervention

PLAN

Plan for ongoing care


NOTE: WE DO NOT WRITE D.A.R.P LETTERS IN THE CHART!!!


NARRATIVE CHARTING

  • Written in Progress Notes

  • Use of a story-like format to document client specific info (condition, nursing care)

  • Organized according to a standard framework

Group dynamic

Factors affecting team performance:

  • Composition

  • Size

  • Norms

  • Cohesiveness

Leadership styles


STRATEGIES FOR HANDLING DIFFICULT GROUP DYNAMICS

  • Know your team (group role, etc.)

  • Tackle problems quickly with good feedback

  • Define roles and responsibilities

  • Break down barriers

  • Focus on communication

  • Pay attention


UNDERSTANDING YOUR OWN STYLE

  • Dealing with difficult situations in teams and work situations is normal and it’s important to develop the skills to work towards a solution with your team members

  • Understanding our own emotional triggers helps us become better communicators,

    listeners, friends, and leaders.

  • High performing teams play to each others strengths and celebrate diversity


5 modes & 2 dimensions


THE THOMAS KILMAN INSTRUMENT

  • The Thomas-Kilmann Instrument is designed to measure your use of conflict-handling modes in various types of group and organizational settings.

  • All five modes are useful in some situations: each represents a set of useful social skills

  • None of us can be characterized as having a single style of dealing with conflict.

  • The overuse or underuse of some areas may lead to difficulty in relationships and unresolved conflict