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USES FOR THE MEDICAL RECORD

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› PERMANENT RECORD

› WRITTEN IN CHRONOLOGICAL
ORDER

› FILED IN MEDICAL RECORDS DEPT

FOR FUTURE USE/REFERENCE



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› SHARING INFORMATION

› FACILITATES EXCHANGE OF
INFORMATION BETWEEN STAFF

› PREVENTS DUPLICATION ERRORS

› (MEDS, DRESSING CHANGE, ACTIVITY, DIETS, ETC.)



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› PATIENT CONFIDENTIALITY
› NEVER LEAVE CHART IN A PUBLIC PLACE.
› DISCUSS CONTENTS ONLY WITH PERSONS
DIRECTLY INVOLVED IN THE PATIENT¶S CARE
OR THOSE THAT ARE AUTHORIZED BY THE
PATIENT. THESE PEOPLE SHOULD BE LISTED BY
NAME.
› ASK FOR ID PRIOR.
› DO NOT DISCUSS PT OR PT INFO IN PUBLIC
PLACES, EG. ELEVATORS, CAFTERIA.



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› ¬UALITY ASSURANCE

› A PEER REVIEW PROCESS

CONDUCTED BY A STAFF NURSE
AND PHYSICIAN
› ESTABLISHES AND REFLECTS
AGENCY STANDARDS
 


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› ACCREDITATION
› JCAHO (JOINT COMMISSION ON
ACCREDITATION OF HEALTH
ORGANIZATION)/DSHS STATE
(EXTENDED CARE)
› SETS MINIMUM STANDARDS FOR
STAFFING
› THE AMERICAN NURSE¶S ASSOCIATION
SETS THE STANDARDS FOR PT CARE &
DOCUMENTATION FOR NURSE¶S



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› SIX ITEMS THAT NURSES MUST

DOCUMENT
› ASSESSMENT
› NURSG DX AND PT NEEDS
› INTERVENTIONS
› CARE PROVIDED
› PT RESPONSE TO CARE
› PTS ABILITY TO MANAGE CONTINUING
CARE AFTER DISCHARGE



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› REIMBURSEMENT

› LACK OF DOCUMENTATION MAY

RESULT IN DENIAL FOR PAYMENTS
FROM MEDICARE AND PRIVATE
INSURANCE COMPANIES. THIS PUTS
THE BURDEN OF PAYMENT ON THE
PATIENT.



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› RESEARCH
› DATA ON TREATMENTS, MEDS, AND
THERAPY
› INFO FOR TUMOR BOARDS, DOCTOR¶S
ROUNDS, NURSING ROUNDS, ETC.
› BE AWARE OF PRIVACY ISSUES
› NURSES, STUDENT NURSES USE FOR
CARE PLANS.



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› LEGAL EVIDENCE
› RECORDS ARE CONSIDERED LEGAL OR
POTENTIAL LEGAL DOCUMENTS
› MAY BE SUBPEONAED AS EVIDENCE BY
ATTORNEY OR NURSING BOARDS. CHECK FOR
DEVIATIONS FROM FACILITY POLICY OR
STANDARDS.
› EACH HEALTH CARE PROVIDER IS RESPONSIBLE
FOR THE ABC¶S OF RECORDING. ACCURACY,
BRIEF, COMPLETE.
ACCESS TO CHARTS
› PATIENT¶S RIGHTS

› WHO OWNS
CHART

› AGENCY POLICY

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› PATIENT¶S RIGHTS/AGENCY POLICY

› PATIENTS HAVE THE RIGHT TO THE INFO

IN THEIR CHARTS.
› THEY DO NOT HAVE THE RIGHT TO SEE
THE CHART ON DEMAND OR REMOVE
ANYTHING FROM THE CHART, OR
REMOVE THE CHART FROM THE
FACILITY.

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› WHO OWNS THE CHART

› A PATIENT¶S CHART IS THE

PROPERTY OF THE FACILITY. IT IS
THE FACILITY WHICH SETS THE
POLICY AND MAKES
APPOINTMENTS FOR VIEWING OF
THE CHART.
TYPES OF PATIENT RECORDS

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› SOURCE ORIENTED
› MOST TRADITIONAL
› DIFFERENT DISCIPLINES CHART ON
SEPARATE FORMS.
› EACH READER MUST CONSULT
VARIOUS PARTS OF THE RECORD TO
GET A COMPLETE PICTURE.
› RECORDS BECOMES BULKY.
 



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› PROBLEM ORIENTED
› COMMONLY REFERRED TO AS POR.
› ORGANIZED ACCORDING TO PROBLEM.
› FOUR PARTS:
A. DATA BASE. THE PATIENTS PRESENT
HEALTH STATUS.
B. PROBLEM LIST. NUMBERED LIST OF
HEALTH PROBLEMS.
C. INITIAL PLAN. PLAN TO HELP OVERCOME
HEALTH PROBLEMS.
D. PROGRESS NOTES. ALL DISCIPLINES CHART ON
SAME PAGE.
 METHODS (STYLES) OF CHARTING

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 NARRATIVE
› CHRONOLOGICAL
› BASELINE CHARTED ¬SHIFT

› LENGTHY, TIME-CONSUMING

› SEPARATE PAGES FOR EACH

› SOURCE-ORIENTED
 SOAP
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 EXAMPLE OF SOAP CHARTING

› #1


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 FOCUS CHARTING
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 EXAMPLE OF FOCUS CHARTING

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  #7

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" 

›
 
 
 ! 

 
 9#   
$
 PIE CHARTING
› Similar to SOAP charting
› Both are problem-oriented
› PIE comes from the 
  
SOAP comes from a  
› P- 
› I© 
› E©

 
SAMPLE OF PIE CHARTING

› P#1 Risk for trauma related to dizziness.

› IP#1 Instructed to call for assistance when

getting OOB. Call light in reach.

› EP#1 Consistently call for assistance

before getting OOB. Continues to
experience dizziness.
 CHARTING BY EXCEPTION

› USES FLOWSHEETS

› EMPHASIS ON ABNORMAL (WHAT IS

ABNORMAL FOR THIS PATIENT.

› ALTHOUGH IT MAY BE ABNORMAL FOR THE

³NORMAL´ PERSON, IF IT IS ABNORMAL FOR
YOUR PATIENT ON A CONSISTENT BASIS, IT IS
NO LONGER CONSIDERED AN ³EXCEPTION´.

› ADVANTAGE
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› PASSWORD. NEVER SHARE. CHANGE FRE¬UENTLY.

› LEGIBLE
› CAN BE VOICE-ACTIVATED, TOUCH-ACTIVATED.
› DATE AND TIME AUTOMATICALLY RECORDED.
› ABBREVIATIONS AND TERMS ARE SELECTED BY A MENU
PROVIDED BY THE FACILITY.
› TERMINALS ARE USUALLY EASILY ACCESSIBLE, IN PT
ROOMS, CONVENIENT HALLWAY LOCATIONS.
› MAKE SURE TERMINAL CANNOT BE VIEWED BY
UNAUTHORIZED PERSONS.
 PARDEX
› ¬UICK REFERENCE

› CHANGED AS NEEDED

› NOT PART OF PERMANENT RECORD






› YOU MUST USE YOUR FACILITY¶S

APPROVED ABBREVIATIONS.
› BE AWARE THAT A LOT OF
COMMONLY USED ABBREVIATIONS:
EG. TID, BID, ¬OD, HS ARE NO
LONGER ALLOWED AND SHOULD
BE CURRENTLY BEING PHASED OUT
OF YOUR FACILITY.
 CHANGE OF SHIFT REPORT

› PERSON TO
PERSON
› BE PREPARED
› AVOID
GOSSIP/SOCIALIZA
TION
› TAPE RECORDER
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› OBJECTIVE
› DO NOT BLAME OR
ADMIT LIABILITY
› WHAT DID YOU DO?
› DO NOT INCLUDE
NAMES/ADDRESSES OF
WITNESSES
› DOCUMENT TIME/NAME
OF DOCTOR
› DO NOT FILE IN CHART
› DO NOT WRITE ³INCIDENT
REPORT MADE´
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› IF YOU SPILL SOMETHING ON THE CHART, DO NOT

DISCARD NOTES. RECOPY, PUT ORIGINAL AND COPIED
SHEETS IN CHART. WRITE ³COPIED´ ON COPY.

› DO NOT SCRIBBLE OUT CHARTING.

› AVOID USING ³ERROR´ OR ³WRONG PATIENT´ WHEN

MAKING CORRECTION.

› FOLLOW YOUR FACILITIES POLICY.

› DO NOT ALTER CHARTING, IT IS A LEGAL DOCUMENT.