Documentation and Proper Charting

1. Documentationand Proper Charting

2. Good Charting is • The most reliable method for substantiating your professional activities • Your first line of defense against malpractice or negligence lawsuits • Crucial data used by your employer to obtain reimbursement for services you provide to patients • Important information for licensing, accreditation, & effort to improve quality of health care

3. Charting or documentation is the process of preparing a complete record of a patient’s care. • Includes: • Nursing admission history (nsg history & physical assessment) • Nursing progress notes (record of the nsg process) • Flow sheets (record of repeated measurements; V/S) • Graphics/neuro checks/diabetic records

4. Intake & output/IV fluids • Medication records (MAR) • Medical history (initial exam by physician) • Doctors orders (Dr orders for meds & treatment) • Doctors progress notes (ongoing record of pt progress & response to therapy) • Informed consent for treatment & procedures • Pre-op checklists • Summary of operative procedures • Discharge plan & summary (summary of pt condition, progress, prognosis, & teaching needs at the time of discharge)

5. Criteria for Effective Documentation & Reporting • Factual – descriptive, objective, factual information • Accurate – precise measurements, avoid statements such as “drank adequate amount” instead should have “intake 1000ml over 8 hrs” • Correct spelling/grammar – use accepted abbreviations & appropriate medical terminology

6. 4)Signed entries – use black ink & sign J Ryan StFX II 5)Concise – complete sentences not necessary, use key words, concerned with quality not quantity. 6)Thorough – include all relevant subjective & objective data, chart any changes in the patients condition, use PQRST

7. 7)Current – chart at the time of occurrence, esp medications, admission/discharge, transfers/change in status, call to physician. Include the time (military), entries should be in chronological order 8)Organization – follow the nursing process to be organized. Narrative entries should be in logical order. DAR is an excellent example of an organized, concise method of charting 9)Confidentiality – legally & ethically bound to maintain confidentiality

8. Guidelines for Charting: Legal Protection • Do not erase or whiteout an entry. Put a line through it, provide a reason, & sign your initials • Never recopy or throw out the original • Never leave a blank space. Prevents others from tampering with your entry • Write neat & legibly – print if necessary

9. Transcribe orders carefully. If unclear, seek clarification. • Students are not allowed to take verbal orders • Document medications completely (date, time, drug, dose, route, in proper chart) • Document if a drug or treatment has been withheld. Include why & notification of physician

10. Make sure all pages are labeled with the clients identification – addressograph • Correctly identify late entries • Chart only for yourself • Don’t criticize or blame other – defamation of character!! • Document comments from client/family • Question an order?? – chart it

11. Use black ink • If you notify physician – chart it • Document the client’s refusal or inability to give info • Document refusal to comply with nursing care/treatment • Document missing clients – follow institutions policies & procedures

12. Document client falls in nurses notes & fill in an incident report • Document if a client tampers with medical equipment • Document the presence of contraband substances at the bedside • Document any instructions given • Document any changes in the clients condition

13. Document communication about withholding life sustaining Rx. Advanced directives must go on chart • Document use of restraints • Final self – check: re-read notes • Legible/understandable? • Correct format required by agency • Each entry dated, time, & signature

14. A few Charting Systems • Narrative • Focus • Computerized • There are many more, depending on agency

15. Narrative Charting • Is a chronological account of the client’s status, the nursing interventions performed, & the client’s responses • A traditional method that few facilities rely on alone. Often combined with other charting systems.

16. Pros of Narrative Charting • Most flexible of all the charting systems • Suitable in any clinical setting • Strongly conveys your nursing interventions & client’s responses • Combines well with other documentation forms, ie flowsheets, which cuts down on charting time • Uses narration, the most common form of writing

17. Cons of Narrative Charting • You have to read the entire record to find the patient outcome • Difficult to track problems & identify trends in the clients progress • No guide as to what’s important to document, so nurses often document everything, which results in a lengthy, repetitive record • May contain vague or inaccurate language

18. Sample of Narrative Charting

19. Focus Charting • Organized into client centered topics. • Encourages use of assessment data to evaluate these concerns • Works best on acute care settings • Typically write each focus as • a nursing diagnosis (ie risk for infection) • a sign or symptom (ie chest pain) • a patient behavior (ie. unable to ambulate) • an acute change in the clients condition (ie. loss of consciousness) • or a significant event (ie. surgery)

20. In the progress notes, divide information into 3 categories; data (D), action (A), and response (R) • Data – include subjective & objective info that describes the focus • Action – include immediate & future nursing actions based on your assessment of the clients condition. The category also includes changes to the plan of care • Response – describes the clients response to nursing or medical care • Continue to record routine nursing tasks on flowsheets & checklists

21. Pros of Focus Charting • Flexible enough to adapt to any clinical setting • Centers on the nursing process • Information on a specific problem is easy to find • Encourages regular documentation of patient responses • Helps to organize your thoughts & document succinctly & precisely

22. Cons of Focus Charting • Staff may need in-depth training if they are used to charting with another system • Need to use many flowsheets & checklists, which can lead to inconsistent documentation • If you forget to include the patient’s response to interventions, focus charting resembles a long narrative

23. Sample of Focus Charting

24. Computerized Charting • Reduces time spent on documentation & increases accuracy • Helps identify client education needs • Supplies data for nursing research & education • Each person would have their own computer ID number. These codes help maintain client’s privacy

25. Pros of Computerized Charting • Storing & retrieval of information is fast & easy • Can constantly update information • Uses standard terminology, which improves communication among HCP • Always legible • Can send request slips & client information from one terminal to another quickly & efficiently which helps ensure confidentiality

26. Cons of Computerized Charting • If security measures are neglected, can threaten client confidentiality • Standardized phrases & limited vocabulary can make information inaccurate or incomplete • Some people have trouble adjusting to computers • Charting can take extra time if too many nurses try to chart on too few terminals • Expensive to initially establish the system

27. NSHIS • Nova Scotia Hospital Information System • Across the province, except Capital Health (Halifax) • One of the many components is the care plan. From the care plan comes the interventions, assessment screens, outcomes. • Nurses notes used minimally. Use mainly checklists. If notes are used, they are written using focus charting format. Start with a focus & link the notes to the appropriate assessment.

28. Accurate, detailed charting shows the extent & quality of care you’ve provided, the outcome of that care, & treatment and education that the patient still needs.