This document discusses nursing documentation and reporting. It covers charting processes including recording observations, interventions, and communications in a clear, precise manner using correct terminology and abbreviations. Charting provides a permanent legal record and allows for assessment of nursing care quality. Reporting includes verbal reports during shifts of changes, written intershift reports, notifying physicians of significant changes, and written reports to administrators of critical illnesses and unusual occurrences. The document also reviews charting systems like narrative, problem-oriented, and computer-assisted and provides specifics on charting format, errors, and documentation of particular events.
This document discusses nursing documentation and reporting. It covers charting processes including recording observations, interventions, and communications in a clear, precise manner using correct terminology and abbreviations. Charting provides a permanent legal record and allows for assessment of nursing care quality. Reporting includes verbal reports during shifts of changes, written intershift reports, notifying physicians of significant changes, and written reports to administrators of critical illnesses and unusual occurrences. The document also reviews charting systems like narrative, problem-oriented, and computer-assisted and provides specifics on charting format, errors, and documentation of particular events.
This document discusses nursing documentation and reporting. It covers charting processes including recording observations, interventions, and communications in a clear, precise manner using correct terminology and abbreviations. Charting provides a permanent legal record and allows for assessment of nursing care quality. Reporting includes verbal reports during shifts of changes, written intershift reports, notifying physicians of significant changes, and written reports to administrators of critical illnesses and unusual occurrences. The document also reviews charting systems like narrative, problem-oriented, and computer-assisted and provides specifics on charting format, errors, and documentation of particular events.
Charting • The process of recording vital information that is communicated to others. – Facts and figures that are specific, clear and precise – Contains correct language, medical terms and abbreviations – Observations, interventions and communications – Reports to authorities as child or elder abuse Charting • Assessment of quality and effectiveness of nursing care • Permanent record • Assessment of quality and effectiveness of nursing care • Legal Document in the event of litigation or prosecution • If not charted, legally it was not done Charting • Legal Requirements -regulated by state laws -professional standards -Joint Commission on Accreditation of Health Care Organizations [JCAHO] Charting Specifics • Black ball point pen because it microfilms best • Errors are corrected by drawing a single line through the error. Above write “Mistaken Entry” [ME] and your initial. • No white-out, erasers, eradicators, covering-up materials • Error no longer written. Juries associate it with an actual nursing mistake Charting Specifics • Each entry is signed with your first initial, last name and status » J. Smith, SN » R. Jones, RN
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it should appear at the right hand margin of the narrative note. Charting Specifics • Notes are written on each succeeding line • Lines are not omitted • A horizontal line is drawn to “fill up” a partial line • Each entry is dated and timed • Begin with a Capital letter • End with a period Does not have to be complete sentences Charting Specifics • Be accurate • Describe behaviors • Use approved abbreviations and symbols • Spell correctly • Used correct terminology and grammar • Write legibly [Printing is acceptable] • Chart only what you have done • Do not double chart [data appears on a flow sheet] except when the patient has a change in their condition Charting Specifics • If you forgot to chart something do so on the next available line putting the time of the event and not the time you are actually charting it • Physician visits • Time client left and returned to unit including transportation and destination • Medications: dosage, route, site, pain relieved, time worked, and/or side effects • Treatments Charting Specifics • Chart objective facts -ate 100% and not “good appetite” -client/patient c/o placed in quotes “stabbing; “chest pain”; “going down” his “left arm” -objective observations -skin cold and clammy; diaphoretic, -v/s B/P 70/40; Pulse 122 bpm, irregular, 1+; Charting Format • Assessment at the start of the shift • Changes in mental, psychological, physiological conditions • Reactions to procedures or medications • Teaching -Document what was taught and the client’s response Charting Systems • Source-oriented – Data entered according to the source [i.e. nurse, MD, social worker, respiratory therapy etc.] – Form of charting is a narrative – Overall picture is difficult to ascertain Narrative Charting • Used with flow sheets and other systems • Chronological data quickly documented • Familiar form • Used in all types of settings Narrative Charting Disadvantages • Lack of a systematic structure hinders making relationships between data • Requires time • May lack information concerning client outcomes • Quality Assurance monitoring more difficult • Relevant data found in several places Charting Systems • Problem-oriented -Data organized based on problems -Each member of the health team documents on the same problem -The overall picture can be seen easily -Focus is on the client and not on the person or department reporting Problem-Oriented Medical Records POMR • Focus is on the client • One set of progress notes is used by all persons caring for the client • Format is called SOAP or SOAPIE POMR: SOAP or SOAPIE • Subjective • Objective • Assessment • Plan • Implementation • Evaluation Charting Systems • Computer-Assisted -Data legible -Quick access to data and information between departments -Easily retrievable -Quick assess to data -Confidentiality maintained -Bedside computers increase accuracy and speed of charting -Meet JCAHO standards -Increase speed and completeness of reimbursement REPORTING: INTRASHIFT • Verbal reports during your shift to other team members -Significant changes in Vital signs -Unusual reactions to treatments, procedures, medications - Changes in physical or psychological condition Reporting • Intershift – Verbal or tape recorded – Client’s Name, Age, Room Number, MD, Diagnosis, Date of Surgery – Changes or unusual occurrences – Laboratory results, studies, tests to be done on next shift – Physical or psychological problems REPORTING: MD NOTIFICATION • Significant changes in physical assessment, abnormal laboratory findings, test results • Identify self to MD by name, status, unit and client’s name • State exact reason why you are calling • Current vital signs, laboratory results, medications etc. should be available REPORT to NURSING ADMINISTRATORS • Written or Verbal each shift • Data on critically ill clients • Unusual occurrences • Problems with clients, families or other disciplines INCIDENT REPORT • Unusual Occurrence, Variance or Incident Report [IR] • Helps to document quality care • Identify areas where staff development is needed • Maintain detailed record of incident for possible legal action Thank You TT
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