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Documentation

The Act of Communicating


among members of the
health team profession
through patients records

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Purposes

Communication
Planning client care
Quality management/auditing
Research
Education
Legal purpose

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Tools for Documentation

Worksheets and Kardexes


Client care plans
Flow sheets and checklist
Care maps and clinical pathways
Monitoring strips

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Reasons for
Documentation
Facilitate Communication
Promote good nursing care
Meet professional and legal
standards

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When & Where do you chart?


According to agencys policy
On the forms provided by the
agency

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When do you need to record ASAP?


After initial assessment or
transfer
Record analgesics stat after
administration
Record prior to leaving the
patient for a long period of
time
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ABCs of Charting
A- Accurate
B- Brief
C-Complete

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GENERAL
GUIDELINES
IN
CHARTING
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General Guidelines
Date & Time
8:00 am
8:00 pm
Military time avoids confusion
0800H
2000H

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Guidelines in charting
Sign all entries

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Guidelines in charting
Document from first
hand knowledge

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General Guidelines
Timing
Document after care
Not before or after a lapse of
how many hours

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Legibility

Subclavian catheter due for flushing with


heparinized saline at 4 pm
Subclavian catheter due for flushing with
heparinized saline at 4 pm

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Permanence
Dark ink and permanent ink

Turn to sides 2 hourly


Turn to sides 2 hourly

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Accepted terminology

D/C- could mean Discharge or


discontinue

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Correct spelling

Received patient on bid, conscious and


ambulatory.

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Signature
Amal Awad, BSN
J. Thomas, RN

9.3.29

9.3.29

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Accuracy
patient refused medications
accurate
patient is uncooperative
Vague

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Bone Marrow aspiration done by


Mistaken entry
Dr. Rashid Ahmed Dr. Marzouk
Khalaf result to follow-up

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Seen and examined by Dr. Ziyad.


Referral letter for angioplasty to KFSH
Sent, To follow up.

Hassan Adnan,
R.N,BSN
28/01/16

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Sequence/

Organization

-Latest temp 37.8C


-Throat swab sent to laboratory
prior to starting antibiotics
-TSB given
-T- 40 C, complaining of chills
and difficulty in swallowing

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Appropriateness
IRRELEVANT
Watcher entertaining male visitors
during visiting hours are
over and leaving the patient
most of the time.

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Completeness

Care that is not recorded is considered


not done

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Legal

prudence

Use steps of the nursing process as


framework that is the best defense
against malpractice.

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What
When
Where
Who
Why
How

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Entry No. 1
6/6/00 0900 IV heplock started in left
hand...........RNavuluri, RN
Entry No. 2
6/6/00 0900 IV heplock started in left
hand using 20 G cathlon, and start kit per
telemetry protocol................RNavuluri,
RN

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When we invoke the six honest servants,


entry no. 1 will provide answers to when,
what, where, and who, but not to the
remaining two questions, why and how.
When.....6/6/00 0900
What ..... IV heplock started
Where..... in left hand
Who .....RNavuluri, RN

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Entry No.2 will provide answers to the six


questions as follows:

When ..... 6/6/00 0900


What ..... IV heplock started
Where ..... in left hand
Who ..... RNavuluri, RN
Why ..... per telemetry protocol
How ..... using 20 G cathlon,
and start kit

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Focus Charting- focused on client concerns or


behaviors
Data
Action
Response
SOAPIE/APIE- problem oriented approach
Narrative- written in chorological order
following specific time frame but no
organizing framework

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