Professional Documents
Culture Documents
Documentation 123
Documentation 123
Module 10-123
Documenting
Recording
OR Charting
DOCUMENTING
DOCUMENTING
personnel involved in a patients health care contribute to the medical record by charting, recording, or documenting (process of writing information) on the health agencys forms. Medical record, also called a chart or client record, is a formal, legal document that provides information about a persons health problems, the care provided by health practitioners, and the progress of the patient. Although health care organizations use different systems and forms for documentation, all client records have similar information.
Documenting
Purposes of client records
A.
B. C.
D.
Documenting
Purposes of client records
E.
F.
G.
Documenting
Types of Patient Records
1.
2.
Documenting
Purposes of client records
Component Description
Database Problem list Plan of care Progress notes
Contains initial health information Consists of a numeric of the patients health problems Identifies methods for solving each identified health problem describes the patients response to what has been done & revisions to the initial plan
Documenting
Methods of Charting
1.
involves writing information about the patient and patient care in chronologic order. (Figure 1)
Documenting
Types of Patient Records
2.
acquired its name from the four essential components included in a progress note:
* S : subjective data * O : objective data * A : analysis of the data * P : plan for care
SOAP charting helps to demonstrate interdisciplinary cooperation, because everyone involved in the care of a patient makes entries in the same location in the chart. (Table 2)
Documenting
Types of Patient Records
Letter
Subjective
Objective Analysis Plan
Explanation
Information reported by the patient
Nurses Remarks
S - Dont feel well
O - Temperature 38C
Problem identification
A Fever
Proposed treatment
Documenting
Types of Patient Records Focus charting: Focus charting (modified form of SOAP
Charting) uses the word focus rather than problem,
because some believe that the word problem carries negative connotations. Focus charting used DAR model: D = data category reflects the assessment phase of the nursing process A = action category reflects planning & implementation phase of the nursing process. R = response category reflect the evaluation of the nursing process (Figure 2). DAR notation tends to reflect the steps in the nursing process.
Documenting
Types of Patient Records
6/6/2006
10.15 am
D (data) -
A (action) Assisted to toilet. Water turned on at faucet R (response)- voided 525ml of clear urine L. Cass, SN
Documenting
Types of Patient Records
4.
PIE charting:
PIE charting is method of recording the patients progress under the headings of problem, intervention, and evaluation. When the PIE method is used, assessments are documented on separate form and the patients problems are given a corresponding number (Figure 3).
Date/time
6/6 8.30 am
Nurses Remarks
P# 1 crackles heard on inspiration in the bases of R and L lungs. I# 1 splinted with pillow. Instructed to breathe deeply, open mouth, and cough at the end of expiration. E# 1 Lungs clear with coughing. L Cass, HN
Documenting
Types of Patient Records 5. Computerized Charting: Computerized charting (documenting patient information electronically) is most useful for nurses when a terminal is available at the point of care or beside
Documenting
General Guidelines for Recording
Because the clients record is a legal document and may be used to provide evidence in court, many factors are considered in recording. 1. Data & Time: Documenting the date and time of each
recording. This is essential not only for legal reasons but also for client safety. Record the time in the conventional manner (e.g. 9:00 am or 3:20 pm) or according to the 24-hours clock (military clock).
2.
3.
Documenting
General Guidelines for Recording
4.
5.
6.
7.
8.
Documenting
General Guidelines for Recording
9.
Good Luck