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 PATI ENT 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 ON SAME PAGE.
METHODS (STYLES) OF CHARTI NG NARRATIVE SOAP SOAPIER FOCUS DATA ACTION RESPONSE PIE EXCEPTION CHARTING NARRATI VE 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 CHARTI NG #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 FOCUS CHARTI NG USES NARRATIVE DOCUMENTATION (DAR) DATA SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE FOCUS (CONCERN)
ACTION NURSING INTERVENTION
RESPONSE PT RESPONSE TO INTERVENTION
EXAMPLE OF FOCUS CHARTI NG 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.
PI E CHARTI NG 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 PI E CHARTI NG 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 experience dizziness. CHARTI NG BY EXCEPTI ON 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 SHI FT REPORT
PERSON TO PERSON BE PREPARED AVOID GOSSIP/SOCIALIZA TION 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.