CHARTING

CHARTING

• Documentation: Essential for maintaining accurate health care records.

Content Overview

• Health Care Record

  • Ethical Consideration

  • Goals/Functions of Documentation

  • Guidelines

  • Charting Do’s and Don’ts

  • Legal Implications

• Types of Nursing Progress Notes

• End of Shift Report

• Patient Discharge Instruction

Goals / Functions of Documentation

Why Document?

• Improve Quality of Patient Care

  • Ensures quality and safety in patient management.

• Ensure Documentation of Progress

  • Tracks patient’s health overtime and continuity of care.

• Link Between Caregivers

  • Enhances communication among healthcare teams.

• Accurate Picture of Patient's History

  • Provides a detailed record from admission to discharge.

• Billing and Medical Necessity

  • Required for insurance claims and reimbursements.

• Research and Education

  • Utilized in studies for improved patient outcomes.

Additional Functions of Documentation

• Facilitate Diagnosis and Treatment

• Evaluation/Nursing Audit

  • Measures nursing effectiveness and outcomes.

• Training and Supervision

  • Used as a reference for new nurses and staff training.

• Reimbursement

  • Ensures payment for services rendered.

• Accreditation

  • Required for compliance with standards by organizations like Joint Commission.

• Legal Documentation

  • Vital for legal protection in case of disputes.

• Serves as Your Memory

  • Helps recall patient details and actions taken.

Key Components of Nursing Documentation

• Assessments

  • Initial and ongoing observations.

• Identified Patient Needs

  • Understanding requirements for care.

• Planned Care

  • Outline of nursing interventions and treatment plans.

• Revisions of Planned Care

  • Updating care as needed based on patient condition.

• Nursing Interventions

  • Documenting actions taken in the patient's care.

• Patient Teaching

  • Evidence of education provided to patients and families.

• Patient Outcomes

  • Achievements or failures relative to expected outcomes.

Essential Information to Chart

• Behavior Changes or Changes in Consciousness

• Physical Functions Changes

  • Include severe or persistent symptoms.

• Signs or Symptoms

  • Document anything that increases or indicates complications.

• Prior Nursing Interventions

  • Summary of care provided.

• Visits by Healthcare Team Members

• Patient Transfers

  • Note reasons and locations of transfer.

• Patient/Family Education

  • Document discussions regarding care.

• Chain of Command Issues

  • Report any concerns regarding care provision.

• Adverse Event Facts and Interventions

Charting DOs

• Pre-read Previous Nursing Notes

• Be Concise

  • Keep notes brief yet informative.

• Document Actions Taken Clearly

• Correctly Sign or Log Each Entry

• Be Definite

  • Ensure clarity in your documentation.

• Patient Identification

  • Always include patient’s name and ID.

• Be Accurate and Factual

  • Avoid assumptions; stick to evidence.

• Legible Writing and Correct Spelling

  • Ensure that all entries are easily readable.

• Use Accepted Abbreviations

  • Consistency in terminology used.

• Nonjudgmental Language

  • Maintain professionalism in language.

• Date and Time Each Entry

  • Identify when documentation takes place.

  • If entries are late, indicate accordingly.

Charting DON’Ts

• Avoid Charting Before Patient Verification

• Do Not Skip Lines or Spaces

• Avoid Charting in Advance

• Never Wait to Document Until Shift End

• Correct Use of Medical Terms

  • Incorrect usage can lead to misunderstandings.

• No Backdating or Tampering with Notes

  • Use an addendum for late entries.

• Refrain from Repetition

  • Don't duplicate what's already recorded unless necessary.

• No Erasing or Altering Records

  • Preserve the integrity of original entries.

How to Document a Mistaken Entry

• Draw a Single Line through the Entry

• Mark Entry as Mistaken

• Initial and Date/Time for Clarity

• For Computer Documentation, Modify as Necessary

Types of Nursing Progress Notes

• Traditional/Narrative

• SOAP

• DART

Narrative Charting Example

• Date/Time: 03/9/12 0800

  • Patient Information: Mr. Gray, epigastric pain rated +5/10

  • Intervention: Mylanta 30 ml administered.

  • Patient Monitoring: Elevated HOB, follows up at 0830.

Types of Charting Styles

PIE Charting

• P: Problem

• I: Intervention

• E: Evaluation

SOAP Charting Components

• S: Subjective

• O: Objective

• A: Assessment

• P: Plan

DART Charting Components

• D: Data

• A: Action

• R: Response

• T: Teaching

Charting by Exception

• Notation only on exceptions to norm/charting standards.

Use of Computers in Documentation

Advantages

• Enhanced Data Management

• Improved Communication

• Facilitated Patient Education

• Increased Systematic Approach to Care

Practical Advantages

• Legibility and Accuracy

a. Timely Data and Rapid Communication

• Definite Document Accountability

• Reduced Medication Errors

Disadvantages

• Malfunction Concerns

• Impersonal Interaction

• Privacy Issues

• Inaccurate Information Dissemination

Types of Computerized Records

• Thorough history and assessment information.

• Care Plans using NANDA diagnoses.

• Comprehensive nursing notes.

• Medication administration sheets.

Verbal Reporting

End of Shift Report

• Purpose: To relay important patient information.

• Tool: SBAR METHOD

• Different methods: Oral report, audiotape, walking rounds.

Elements to Include in Report

• Basic Identifying Information

  • Name, age, room number, admission date, medical diagnosis.

• Description of Current Patient Condition

• Significant Changes and Goal Progression

• Discharge Planning and Additional Therapy Results

What Not to Include in a Report

• Gossip or Unprofessional Comments

• Routine Procedure Details

• Redundant Information

SBAR Communication Structure

• Situation: Presenting issue.

• Background: Patient history pertinent to the situation.

• Assessment: Clinician’s assessment of patient condition.

• Recommendation: Suggested next steps or evaluations.

Charting Procedure Summary

• Identify Relevant Information

• Document in the Correct Location

• Final Check for:

  • Legibility

  • Factuality

  • Completeness

  • Organizational Clarity

  • Current Date/Time/Signature