CHARTING

Prepared by:
Amelia Filio Nacario R.N. MAN

TOP TEN NCM 104

1. Nunez, Michelle
- 90.62
2. Odiaman, Manilyn 88.96
3. Colarina, Melody Arianne 88.3
4. Brina, Anna Lizza 87.26
5. Esta, Myra

86.27

6. Andal, Rolando
7. Cortez, Mary Jane
8. Sunaz, Evelyn
9. Llagas, Mischel
10. Lamadrid, Jesse
84.56

86.20
86.12
85.80
84.91

TOP TEN RLE 104

1. Cortez, Mary Jane
89.95
2. Nunez, Michelle

89.44
3. Brina, Anna Lizza

88.91
4.Colarina, Melody Arianne 88.44
5. Bismonte, Romualdo 87.95

6. Rempillo, Chrislene
7. Odiaman, Manilyn
8. Lamadrid, Jesse
9. Andal, Rolando
10. Perdigon, Joy

87.97
87.13
87.08
87.05
86.96

 The purpose of preparing a

complete record of patients care.
Accurate, detailed charting shows
the extent and quality of the care
the nurse provided and the
outcome of that care.

Proper charting is important for

many reasons:
1. Establish your responsibility and
accountability.
2. A vital tool communication among
health care team members.
3. Decisions, actions and revisions related to
the patient care are based on charting from
various team members.

4. Shows the high degree of collaboration

among health care team members.

5. Be easily retrievable and readable as
well.
6. Notes must be clear, concise and in an
organized manner.

Role of Charting
1. Its mode of communication among
health care professionals.
2. Its checked in health care evaluation.
3. Its legal evidence that protects you.
4. It is used to aid research and education.

 5. It helps facilities obtain accreditation and

license.
6. It is used to quantify reimbursement.
7. It is used to develop improvement in the
quality of care.

Importance of Improving
Documentation
It is one of the most important function of a
nurse next to direct patient care.
It communicates our observation and
actions for continuity of quality of care thru
coordination.
It provides effectiveness of care thru
assessment, reflecting current nursing
standards.

 It protects the nurse, the

patient and the hospital in
possible law suits.

General Standards Set by Most

Nursing Associations on
Documentation

Systematic
Continuous
Accessible
Recorded
Readily available to all members of the
health care team.

Specific Standards on Nursing

Documentation
Standard I Structural Data
Nurse documents structural data of each
patient accurately and completely based on
applicable laws and regulation, professional
standards and institutional requirements.

Rules on How to Chart

1.
2.
3.
4.
5.
6.

Stick to facts
Avoid labeling
Be specific
Use neutral language
Eliminate bias
Keep the record intact

 Soiled entries are not discarded.

Copy it and put the copy and the
original in the chart.
Write recopied from the page on
the copy and recopied on the page
on the original.

Rules on What to Chart

1. Chart significant situations
recognize legally dangerous
situations as you give patient care.
2. Chart complete assessment data
it is the key factor in many
malpractice suits. Be sure to chart
everything you do and why.

3. Document

discharge instruction
when inadequate or incorrect
instructions are given, it may
result to injury and may hold
you liable.

Rules on WHO Should Chart

No matter how busy you are, never
ask another to complete your
charting, it destroys credibility and
value of the record. Second hand
observation are hear say evidence.

Advanced Directives
1. Living Will
legally competent person declares what
medical care he wants or doesnt want if he
develops terminal illness and has no
reasonable chance of recover.

2. Durable Power of Attorney

enables a person to state what type

of care he wants, also names another
person to make health care choices if
the patient becomes legally
incompetent.
DNR policies are included under
advance directives.

3. Patient refused treatment when a patient

refused treatment, chart his exact words,
explain the risks involved in writing. Let
the patient sign a waiver, including the
closest relative.
A patients decision to withhold
treatment must be recorded carefully.

4. Using

Restraints
Check frequently for problems
associated with restraints, perform
ROM exercises on all extremities,
follow institutions policies.

5. Patient who Request to SEE his Chart

A patient has a legal right to read

his record, however, ask him first if he
has questions about the treatment.
Check the hospitals policy. Document
questions asked or statements made.
Never release records to
unauthorized persons.

6. Patients who Leave Against Medical

Advice
The AMA/HAMA form should ne
accomplished completely and accurately.
Patients mental state and condition
from the time he left the hospital should be
documented.

7. The Case of the Missing Patient

If the patient is not found within the
hospital premises, Notify the Police.
Chart the following:
a. the time of discovery
b. attempts to find the patient
c. people you notified
d. other pertinent informations

4 ELEMENTS of FOCUS
CHARTING

FOCUS
DATA
ACTION
RESPONSE

FOCUS identifies the contents or

purpose of the narrative entry
and is separated from the body
of the notes in order to promote
easy data retrieval and
communication.

FOCUS is used to:

1.
2.
3.
4.

Describe a patient
Identify an exception
Document a new finding
Document an acute change in the patients
condition

5. Document a significant or unusual

episode in the patient care
6. Document an activity or treatment that
was not carried out
7. Describe all specifics regarding
patient/family teaching
8. Identify the discipline as well as the
topic of the note.

DATA
Subjective or objective information
supporting the stated focus or
describing the observation at the
time of a significant event.

PAIN

Precipitating factor
Quality
Radiation
Severity
Time
Aggravating Factors
Alleviating Factors

ACTION
Describes the nursing interventions (past,
present, future)
Basic Interventions (ADLs)
bathing
feeding
toileting
mobility
dressing

Independent Interventions Health Teachings

Medication
Exercise
Treatment
Health disease/hygiene
Out patient follow up
Diet
Sexuality/psychosocial

Prescriptive Interventions
1. Do read what and when
2. Do use flow sheet/checklist
3. Do write observations, your name and time
of entry
4. Do record exactly what happened to the
patient and the care given.

 5. Do use the next available line to chart

6. Document patients current status and
response to medical care and treatment
7. Do write legibly
8. Do use ink
9. Do use accepted/approved abbreviations
only.
10. Do use institutions chart or forms

 11. Document the patients response to

medications and other treatment
12. Document safeguards you used to
protect the patient
13. Document procedures only after
you have performed them.

THANK YOU