CHARTING

USES FOR THE MEDICAL RECORD

PERMANENT ACCOUNT
TRACKS PT
PROGRESS/CARE GIVEN

SHARING INFORMATION
PATIENT
CONFIDENTIALITY

6 ITEMS THAT MUST BE

DOCUMENTED
INSURANCE
REIMBURSEMENT
RESEARCH
LEGAL EVIDENCE FOR

QUALITY ASSURANCE
ACCREDITATION

MALPRACTICE SUITS
ASSURES CONTINUITY OF
CARE

USES FOR THE MEDICAL RECORD

PERMANENT RECORD
WRITTEN IN CHRONOLOGICAL

ORDER
FILED IN MEDICAL RECORDS DEPT

FOR FUTURE USE/REFERENCE

USES FOR THE MEDICAL RECORD

SHARING INFORMATION
FACILITATES EXCHANGE OF

INFORMATION BETWEEN STAFF

PREVENTS DUPLICATION ERRORS
(MEDS, DRESSING CHANGE, ACTIVITY, DIETS, ETC.)

USES FOR THE MEDICAL RECORD

PATIENT CONFIDENTIALITY
NEVER LEAVE CHART IN A PUBLIC PLACE.
DISCUSS CONTENTS ONLY WITH PERSONS

DIRECTLY INVOLVED IN THE PATIENTS 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.

USES FOR THE MEDICAL RECORD

QUALITY ASSURANCE
A PEER REVIEW PROCESS

CONDUCTED BY A STAFF NURSE

AND PHYSICIAN
ESTABLISHES AND REFLECTS
AGENCY STANDARDS

USES FOR THE MEDICAL RECORD

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

USES FOR THE MEDICAL RECORD

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

USES FOR THE MEDICAL RECORD

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.

USES FOR THE MEDICAL RECORD

RESEARCH
DATA ON TREATMENTS, MEDS, AND
THERAPY

INFO FOR TUMOR BOARDS, DOCTORS

ROUNDS, NURSING ROUNDS, ETC.
BE AWARE OF PRIVACY ISSUES

NURSES, STUDENT NURSES USE FOR

CARE PLANS.

USES FOR THE MEDICAL RECORD

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 ABCS OF RECORDING. ACCURACY,
BRIEF, COMPLETE.

ACCESS TO CHARTS
PATIENTS RIGHTS
WHO OWNS

CHART
AGENCY POLICY

ACCESS TO CHARTS
PATIENTS 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.

ACCESS TO CHARTS
WHO OWNS THE CHART
A PATIENTS 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

SOURCE-ORIENTED

PROBLEM-ORIENTED

TYPES OF PATIENT RECORDS

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.

TYPES OF PATIENT RECORDS

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

NARRATIVE
SOAP

SOAPIER
FOCUS
DATA
ACTION
RESPONSE
PIE
EXCEPTION CHARTING

NARRATIVE
CHRONOLOGICAL
BASELINE CHARTED QSHIFT
LENGTHY, TIME-CONSUMING

SEPARATE PAGES FOR EACH

SOURCE-ORIENTED

SOAP
USED FOR PROBLEM-ORIENTED CHARTS
S SUBJECTIVE. WHAT PT TELLS YOU.
0 OBJECTIVE. WHAT YOU OBSERVE, SEE.
A ASSESSMENT. WHAT YOU THINK IS GOING ON

BASED ON YOUR DATA.

P PLAN. WHAT YOU ARE GOING TO DO.
CAN ADD TO BETTER REFLECT NURSING PROCESS
I INTERVENTION (SPECIFIC INTERVENTIONS
IMPLEMENTED)
E EVALUATION. PT RESPONSE TO INTERVENTIONS.
R REVISION. CHANGES IN TREATMENT.

EXAMPLE OF SOAP CHARTING

#1 ALTERATION IN COMFORT. ABDOMINAL

PAIN.
S COMPLAINS OF PAIN IN RUQ
O IS PALE AND HOLDING RIGHT SIDE
A RECURRING ABDOMINAL PAIN
P PUT ON NPO AND NOTIFY PHYSICIAN

FOCUS CHARTING
USES NARRATIVE DOCUMENTATION
(DAR)
DATA SUBJECTIVE OR OBJECTIVE THAT

SUPPORTS THE FOCUS (CONCERN)

ACTION NURSING INTERVENTION
RESPONSE PT RESPONSE TO INTERVENTION

EXAMPLE OF FOCUS CHARTING

D COMPLAINING OF PAIN AT INCISION SITE

ON LEVEL OF #7
A REPOSITIONED FOR COMFORT. DEMEROL

50MG IM GIVEN.
R (CHARTED AT A LATER DATE.) STATES A

DECREASE IN PAIN, FEELS MUCH BETTER.

PIE CHARTING
Similar to SOAP charting
Both are problem-oriented
PIE comes from the Nursing Process,

SOAP comes from a Medical Model.

P-Problem
I-Intervention
E-Evaluation

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

NORMAL PERSON, IF IT IS ABNORMAL FOR

YOUR PATIENT ON A CONSISTENT BASIS, IT IS
NO LONGER CONSIDERED AN EXCEPTION.

ADVANTAGE

COMPUTERIZED CHARTING
PASSWORD. NEVER SHARE. CHANGE FREQUENTLY.
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.

KARDEX
QUICK REFERENCE
CHANGED AS NEEDED

NOT PART OF PERMANENT RECORD

ABBREVIATIONS
YOU MUST USE YOUR FACILITYS

APPROVED ABBREVIATIONS.
BE AWARE THAT A LOT OF
COMMONLY USED ABBREVIATIONS:
EG. TID, BID, QOD, 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

INCIDENT REPORTS
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 INCIDENT
REPORT MADE

CORRECTING ERRORS
IF YOU SPILL SOMETHING ON THE CHART, DO NOT

DISCARD NOTES. RECOPY, PUT ORIGINAL AND COPIED

SHEETS IN CHART. WRITE COPIED ON COPY.
DO NOT SCRIBBLE OUT CHARTING.
AVOID USING ERROR OR WRONG PATIENT WHEN

MAKING CORRECTION.
FOLLOW YOUR FACILITIES POLICY.
DO NOT ALTER CHARTING, IT IS A LEGAL DOCUMENT.