CHARTING

Prepared by: Amelia Filio Nacario R.N. MAN

TOP TEN NCM 104

1. Nunez, Michelle - 90.62 2. Odiaman, Manilyn 88.96 3. Colarina, Melody Arianne 88.3 4. Brina, Anna Lizza 87.26 5. Esta, Myra 86.27

6. Andal, Rolando 7. Cortez, Mary Jane 8. Sunaz, Evelyn 9. Llagas, Mischel 10. Lamadrid, Jesse 84.56

86.20 86.12 85.80 84.91

TOP TEN RLE 104

1. Cortez, Mary Jane 89.95 2. Nunez, Michelle 89.44 3. Brina, Anna Lizza 88.91 4.Colarina, Melody Arianne 88.44 5. Bismonte, Romualdo 87.95

6. Rempillo, Chrislene 7. Odiaman, Manilyn 8. Lamadrid, Jesse 9. Andal, Rolando 10. Perdigon, Joy

87.97 87.13 87.08 87.05 86.96

 The purpose of preparing a complete record of patients care. Accurate, detailed charting shows the extent and quality of the care the nurse provided and the outcome of that care.

Proper charting is important for many reasons:

1. Establish your responsibility and accountability. 2. A vital tool communication among health care team members. 3. Decisions, actions and revisions related to the patient care are based on charting from various team members.

4. Shows the high degree of collaboration

among health care team members. 5. Be easily retrievable and readable as well. 6. Notes must be clear, concise and in an organized manner.

Role of Charting
1. Its mode of communication among health care professionals. 2. Its checked in health care evaluation. 3. Its legal evidence that protects you. 4. It is used to aid research and education.

 5. It helps facilities obtain accreditation and license. 6. It is used to quantify reimbursement. 7. It is used to develop improvement in the quality of care.

Importance of Improving Documentation

It is one of the most important function of a nurse next to direct patient care. It communicates our observation and actions for continuity of quality of care thru coordination. It provides effectiveness of care thru assessment, reflecting current nursing standards.

 It protects the nurse, the patient and the hospital in possible law suits.

General Standards Set by Most Nursing Associations on Documentation

Systematic Continuous Accessible Recorded Readily available to all members of the health care team.

Specific Standards on Nursing Documentation

Standard I Structural Data Nurse documents structural data of each patient accurately and completely based on applicable laws and regulation, professional standards and institutional requirements.

Rules on How to Chart

1. 2. 3. 4. 5. 6. Stick to facts Avoid labeling Be specific Use neutral language Eliminate bias Keep the record intact

 Soiled entries are not discarded. Copy it and put the copy and the original in the chart. Write recopied from the page on the copy and recopied on the page on the original.

Rules on What to Chart

1. Chart significant situations recognize legally dangerous situations as you give patient care. 2. Chart complete assessment data it is the key factor in many malpractice suits. Be sure to chart everything you do and why.

3. Document

discharge instruction when inadequate or incorrect instructions are given, it may result to injury and may hold you liable.

Rules on WHO Should Chart

No matter how busy you are, never ask another to complete your charting, it destroys credibility and value of the record. Second hand observation are hear say evidence.

Advanced Directives
1. Living Will legally competent person declares what medical care he wants or doesnt want if he develops terminal illness and has no reasonable chance of recover.

2. Durable Power of Attorney

enables a person to state what type of care he wants, also names another person to make health care choices if the patient becomes legally incompetent. DNR policies are included under advance directives.

3. Patient refused treatment when a patient refused treatment, chart his exact words, explain the risks involved in writing. Let the patient sign a waiver, including the closest relative. A patients decision to withhold treatment must be recorded carefully.

4. Using

Restraints Check frequently for problems associated with restraints, perform ROM exercises on all extremities, follow institutions policies.

5. Patient who Request to SEE his Chart

A patient has a legal right to read his record, however, ask him first if he has questions about the treatment. Check the hospitals policy. Document questions asked or statements made. Never release records to unauthorized persons.

6. Patients who Leave Against Medical Advice The AMA/HAMA form should ne accomplished completely and accurately. Patients mental state and condition from the time he left the hospital should be documented.

7. The Case of the Missing Patient If the patient is not found within the hospital premises, Notify the Police. Chart the following: a. the time of discovery b. attempts to find the patient c. people you notified d. other pertinent informations

4 ELEMENTS of FOCUS CHARTING

FOCUS DATA ACTION RESPONSE

FOCUS identifies the contents or purpose of the narrative entry and is separated from the body of the notes in order to promote easy data retrieval and communication.

FOCUS is used to:

1. 2. 3. 4. Describe a patient Identify an exception Document a new finding Document an acute change in the patients condition

5. Document a significant or unusual episode in the patient care 6. Document an activity or treatment that was not carried out 7. Describe all specifics regarding patient/family teaching 8. Identify the discipline as well as the topic of the note.

DATA
Subjective or objective information supporting the stated focus or describing the observation at the time of a significant event.

PAIN
Precipitating factor Quality Radiation Severity Time Aggravating Factors Alleviating Factors

ACTION
Describes the nursing interventions (past, present, future) Basic Interventions (ADLs) bathing feeding toileting mobility dressing

Independent Interventions Health Teachings

Medication Exercise Treatment Health disease/hygiene Out patient follow up Diet Sexuality/psychosocial

Prescriptive Interventions
1. Do read what and when 2. Do use flow sheet/checklist 3. Do write observations, your name and time of entry 4. Do record exactly what happened to the patient and the care given.

 5. Do use the next available line to chart 6. Document patients current status and response to medical care and treatment 7. Do write legibly 8. Do use ink 9. Do use accepted/approved abbreviations only. 10. Do use institutions chart or forms

 11. Document the patients response to medications and other treatment 12. Document safeguards you used to protect the patient 13. Document procedures only after you have performed them.

THANK YOU