Documentation

1. Documentation NUR 869

2. Client Record • A permanent legal documentation of information relevant to client’s health care management.

3. Purpose of the record • Communication between team members • Financial Billing • Education • Assessment • Research • Auditing • Legal Documentation

4. CARE NOT DOCUMENTED IS CARE NOT DONE.

5. Common problems in malpractice • Not charting correct time events occurred • Failing to record verbal orders or have them signed • Charting in advance to save time • Documenting incorrect data

6. We are legally and ethically obligated to keep client information confidential.

7. The client can read records with written release of information.

8. 1. Information sheet 2. Graphic sheet 3. Physician’s order sheet 4. Progress notes 5. Flow sheets 6. Consult sheet 7. Laboratory results 8. Consent Form 9. Medication Records 10.Special Records 11.Discharge Summary Components of client record

9. Guidelines for documentation and reporting • Factual • Accurate • Complete • Current • Organized • Confidentiality

10. CONFIDENTIALITY

11. Methods of Documentation • SOAP notes • DAR

12. Charting Bloopers Skin: Somewhat pale but present. The pelvic exam will be done on the floor. She was treated with Mycostatin oral suppositories. By the time she was admitted to the hospital her rapid heart had stopped and she was feeling much better.