CHARTING

USES FOR THE MEDICAL RECORD

PERMANENT ACCOUNT TRACKS PT PROGRESS/CARE GIVEN SHARING INFORMATION PATIENT CONFIDENTIALITY QUALITY ASSURANCE ACCREDITATION 6 ITEMS THAT MUST BE DOCUMENTED INSURANCE REIMBURSEMENT RESEARCH LEGAL EVIDENCE FOR 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 SAME PAGE.

ON

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

USES NARRATIVE DOCUMENTATION (DAR)

DATA SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE FOCUS (CONCERN) ACTION NURSING INTERVENTION RESPONSE PT RESPONSE TO INTERVENTION

FOCUS CHARTING

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

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/SOCIALIZ ATION 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.