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Nursing The Hospitalized Adult > Charting > Flashcards

Flashcards in Charting Deck (24):
1

What is charting?

A confidential, permanent legal documentation of information relevant to a patient’s health care.

2

Who is the chart available too?

Available to all members of the health team

not available to PAB'S

3

Purpose of patient chart?

Communication between team members
Care planning and continuity of care
Legal document
Education
Research
Auditing for Quality Assurance

4

Chart Contents?

Patient identification and demographic data
Informed consent
Admission Nursing History
Nursing Care Maps
TNP (Therapeutic Nursing Plan)
Progress Notes (usually interdisciplinary) Medical History with diagnosis
Medical Orders
Reports of physical examinations, consultations and diagnostic studies
Flow sheets/ Graphic sheets
Summary of operative procedures
Discharge plan and summary

5

Documentation systems?

problem-oriented documentation
source-oriented documentation
computerized documentation

6

Source-oriented documentation?

Chart is organized so that each discipline has a separate section in which to record data.

7

Source-oriented documentation components

Admission sheet
Medical order sheet
Nursing History
Graphic and flow sheets
Medical history and exam
Nurses notes
Medication records
Medical progress notes
Consultations

8

Problem-oriented documentation?

emphasizes the client’s problems.
Data organized by problem or diagnosis

9

Problem-oriented documentation components?

Database
Problem list
Care plan
Progress notes

10

What are progress notes?

Can be reserved for nursing only (i.e. MCH)-source oriented
Can be multidisciplinary-problem oriented

11

Nursing notes in progress notes?

Charting by exception (CBE)
Problem focused (DARP, SOAP, PIE)
or
Narrative charting

12

Computerized Documentation?

Improved uniformity, accuracy and retrievability of data
Confidentiality
Accessibility
Selective retrieval
Assistance with clinical applications.
Availability of a life-long record of health-related events.

13

Nursing Notes:
Charting by Exception (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

14

Charting by Exception (CBE) (Advantages)?

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.

15

Nursing Notes: 
SOAP(IER)?

Subjective
Objective
Assessment
Plan
Intervention
Evaluation
Revision

Associated with problem-oriented medical record
Origins from medical profession

16

Nursing Notes: 
PIE?

PIE
Problem
Intervention
Evaluation

Associated with problem-oriented medical record system
Origin is from nursing process

17

Nursing Notes: 
Focus Charting (DARP)?

According to client concern (the focus).
Focus:
sign, symptom or a condition
nursing diagnosis (SCD)
medical diagnosis
client behaviour
significant event/change in the client’s condition.
Follows the nursing process.

18

Nursing Notes: 
Focus Charting (DAR)?

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

19

Legal Guidelines for Charting: Dos and Don’ts

DO:
Begin each charting entry with the date and time, identify your discipline.
Ensures correct sequence of events is recorded. (military time, dddd/mm/dd)

End each entry with your full signature and title.
Signature indicates who is accountable for the care delivered.

Chart on each line. If space is left, draw a line horizontally through it and sign your name at the end.

Record all entries legibly and in ink, never use pencil (pencil sometimes used for pt cardex, but it is destroyed when pt is dismissed)

Correct all errors promptly

Chart throughout the day

Record all facts.
Be sure entry is factual; do not speculate or guess

For computer documentation, keep your password to yourself.
Maintains security + confidentiality.



DO NOT:
Erase, use “white-out” or scratch out errors made while recording.
Draw a single line through the error and write the word “error” above it. Initial the note.
Write critical comments about the patient or care by other health care professionals.

Document only objective & factual data.

Incorrect: Extremely large pt was admitted…..
Correct: Pt. weight on admission = 70kg….

“pre-chart”.
Pre-charting invites error and endangers the health and safety of the client.

record that an “error” was made with order.
If an order is questioned, record that clarification was sought.

chart for others.
You are accountable for the information you enter into a chart. Never chart for someone else.

Use generalized, empty phrases such as “status unchanged”, “no complains(C/O) voiced” .

Information is too generalized and has no meaning.

20

Guidelines for Quality Charting?

Quality documentation and reporting have six important characteristics:
Factual
Accurate
Complete
Current
Organized
Complies with standards

21

Rules to Remember?

Write legibly and neatly.
Use authorized abbreviations.
Use proper spelling & grammar.
Date all entries and use military time.
Write full name and title at the end of your charting entry.
Chart promptly after delivery of care.

22

Progress Notes: Narrative Charting?

use of a story-like format to document client specific info (condition, nursing care)
organized according to a standard framework

takes long, not used frequently

23

Charting using bio-psychosocial systems:

Respiration / Chest
Cardiovascular (or CVS)
Nutrition / Diet
Urinary elimination (or GU)
Intestinal Elimination (or GI)
Neuro
Mental Status
Skin Integrity (or Skin)
Wound
Dressing
Drainage (includes any type of drain)
Genitalia
Eyes
E.N.T.
VS
IV (site and infusion)
CBGM (Capillary Blood Glucose Monitoring)
Pain
Mobility (includes Musculoskeletal and Activity)
Rest
Safety
Admission Assessment
D/C Planning
D/C Summary
Coping
Psychosocial

24

Other Nursing Documentation?

Flowsheets
Nursing Kardexes (client care summary)
Discharge Summaries
Care Maps/Critical Pathways
Therapeutic Nursing Plan (TNP)