DocumentationDocumentationand Proper Chartingand Proper Charting

Good Charting isGood Charting is

The most reliable method for substantiating your The most reliable method for substantiating your professional activitiesprofessional activities

Your first line of defense against malpractice or Your first line of defense against malpractice or negligence lawsuitsnegligence lawsuits

Crucial data used by your employer to obtain Crucial data used by your employer to obtain reimbursement for services you provide to reimbursement for services you provide to patientspatients

Important information for licensing, accreditation, Important information for licensing, accreditation, & effort to improve quality of health care& effort to improve quality of health care

Charting or documentation is the process of Charting or documentation is the process of preparing a complete record of a patient’s care.preparing a complete record of a patient’s care.

Includes:Includes: Nursing admission history (nsg history & physical Nursing admission history (nsg history & physical

assessment)assessment) Nursing progress notes (record of the nsg process)Nursing progress notes (record of the nsg process) Flow sheets (record of repeated measurements; V/S)Flow sheets (record of repeated measurements; V/S) Graphics/neuro checks/diabetic recordsGraphics/neuro checks/diabetic records

Intake & output/IV fluidsIntake & output/IV fluids Medication records (MAR)Medication records (MAR) Medical history (initial exam by physician)Medical history (initial exam by physician) Doctors orders (Dr orders for meds & treatment)Doctors orders (Dr orders for meds & treatment) Doctors progress notes (ongoing record of pt Doctors progress notes (ongoing record of pt

progress & response to therapy)progress & response to therapy) Informed consent for treatment & proceduresInformed consent for treatment & procedures Pre-op checklistsPre-op checklists Summary of operative proceduresSummary of operative procedures Discharge plan & summary (summary of pt condition, Discharge plan & summary (summary of pt condition,

progress, prognosis, & teaching needs at the time of progress, prognosis, & teaching needs at the time of discharge) discharge)

Criteria for Effective Documentation Criteria for Effective Documentation & Reporting& Reporting

1)1) FactualFactual – descriptive, objective, factual – descriptive, objective, factual informationinformation

2)2) AccurateAccurate – precise measurements, avoid – precise measurements, avoid statements such as “drank adequate statements such as “drank adequate amount” instead should have “intake amount” instead should have “intake 1000ml over 8 hrs”1000ml over 8 hrs”

3)3) Correct spelling/grammarCorrect spelling/grammar – use accepted – use accepted abbreviations & appropriate medical abbreviations & appropriate medical terminologyterminology

4)4) Signed entriesSigned entries – use black ink & sign – use black ink & sign J Ryan StFX J Ryan StFX IIII

5)5) ConciseConcise – complete sentences not – complete sentences not necessary, use key words, concerned with necessary, use key words, concerned with quality not quantity. quality not quantity.

6)6) ThoroughThorough – include all relevant subjective – include all relevant subjective & objective data, chart any changes in the & objective data, chart any changes in the patients condition, use PQRSTpatients condition, use PQRST

7)7) CurrentCurrent – chart at the time of occurrence, – chart at the time of occurrence, esp medications, admission/discharge, esp medications, admission/discharge, transfers/change in status, call to transfers/change in status, call to physician. Include the time (military), physician. Include the time (military), entries should be in chronological orderentries should be in chronological order

8)8) OrganizationOrganization – follow the nursing process – follow the nursing process to be organized. Narrative entries should to be organized. Narrative entries should be in logical order. DAR is an excellent be in logical order. DAR is an excellent example of an organized, concise method example of an organized, concise method of charting of charting

9)9) ConfidentialityConfidentiality – legally & ethically bound – legally & ethically bound to maintain confidentiality to maintain confidentiality

Guidelines for Charting: Legal ProtectionGuidelines for Charting: Legal Protection

Do not erase or whiteout an entry. Put a Do not erase or whiteout an entry. Put a line through it, provide a reason, & sign line through it, provide a reason, & sign your initialsyour initials

Never recopy or throw out the originalNever recopy or throw out the original Never leave a blank space. Prevents Never leave a blank space. Prevents

others from tampering with your entryothers from tampering with your entry Write neat & legibly – print if necessaryWrite neat & legibly – print if necessary

Transcribe orders carefully. If unclear, Transcribe orders carefully. If unclear, seek clarification.seek clarification.

Students are not allowed to take verbal Students are not allowed to take verbal ordersorders

Document medications completely (date, Document medications completely (date, time, drug, dose, route, in proper chart)time, drug, dose, route, in proper chart)

Document if a drug or treatment has been Document if a drug or treatment has been withheld. Include why & notification of withheld. Include why & notification of physicianphysician

Make sure all pages are labeled with the Make sure all pages are labeled with the clients identification – addressographclients identification – addressograph

Correctly identify late entriesCorrectly identify late entries Chart only for yourselfChart only for yourself Don’t criticize or blame other – defamation Don’t criticize or blame other – defamation

of character!!of character!! Document comments from client/familyDocument comments from client/family Question an order?? – chart itQuestion an order?? – chart it

Use black inkUse black ink If you notify physician – chart itIf you notify physician – chart it Document the client’s refusal or inability to Document the client’s refusal or inability to

give infogive info Document refusal to comply with nursing Document refusal to comply with nursing

care/treatmentcare/treatment Document missing clients – follow Document missing clients – follow

institutions policies & proceduresinstitutions policies & procedures

Document client falls in nurses notes & fill Document client falls in nurses notes & fill in an incident reportin an incident report

Document if a client tampers with medical Document if a client tampers with medical equipmentequipment

Document the presence of contraband Document the presence of contraband substances at the bedsidesubstances at the bedside

Document any instructions givenDocument any instructions given Document any changes in the clients Document any changes in the clients

conditioncondition

Document communication about Document communication about withholding life sustaining Rx. Advanced withholding life sustaining Rx. Advanced directives must go on chartdirectives must go on chart

Document use of restraintsDocument use of restraints Final self – check: re-read notesFinal self – check: re-read notes

Legible/understandable?Legible/understandable? Correct format required by agencyCorrect format required by agency Each entry dated, time, & signatureEach entry dated, time, & signature

A few Charting SystemsA few Charting Systems

NarrativeNarrative FocusFocus Computerized Computerized

There are many more, depending on There are many more, depending on agencyagency

Narrative ChartingNarrative Charting

Is a chronological account of the client’s Is a chronological account of the client’s status, the nursing interventions status, the nursing interventions performed, & the client’s responsesperformed, & the client’s responses

A traditional method that few facilities rely A traditional method that few facilities rely on alone. Often combined with other on alone. Often combined with other charting systems.charting systems.

Pros of Narrative ChartingPros of Narrative Charting

Most flexible of all the charting systemsMost flexible of all the charting systems Suitable in any clinical settingSuitable in any clinical setting Strongly conveys your nursing Strongly conveys your nursing

interventions & client’s responsesinterventions & client’s responses Combines well with other documentation Combines well with other documentation

forms, ie flowsheets, which cuts down on forms, ie flowsheets, which cuts down on charting timecharting time

Uses narration, the most common form of Uses narration, the most common form of writingwriting

Cons of Narrative ChartingCons of Narrative Charting

You have to read the entire record to find You have to read the entire record to find the patient outcomethe patient outcome

Difficult to track problems & identify trends Difficult to track problems & identify trends in the clients progressin the clients progress

No guide as to what’s important to No guide as to what’s important to document, so nurses often document document, so nurses often document everything, which results in a lengthy, everything, which results in a lengthy, repetitive recordrepetitive record

May contain vague or inaccurate languageMay contain vague or inaccurate language

Sample of Narrative ChartingSample of Narrative Charting

Date Date TimeTime NotesNotes

11/26/9711/26/97 22452245 Pt 4 hours post-op; awakens easily; oriented x 3 but Pt 4 hours post-op; awakens easily; oriented x 3 but groggy. Incision site in LLQ, 5cm, without dressing, groggy. Incision site in LLQ, 5cm, without dressing, no bleeding, sutures intact. Pt denied pain but stated no bleeding, sutures intact. Pt denied pain but stated she felt nauseated and promptly vomited 100ml of she felt nauseated and promptly vomited 100ml of clear fluid. Pt attempted to get OOB to ambulate to clear fluid. Pt attempted to get OOB to ambulate to the bathroom with assistance, but felt dizzy upon the bathroom with assistance, but felt dizzy upon standing. Assisted to lie down in bed. Voided 200ml standing. Assisted to lie down in bed. Voided 200ml clear, yellow urine in bedpan.------------clear, yellow urine in bedpan.------------MMacNeil MMacNeil RNRN

11/26/9711/26/97 22552255 Pt continues to feel nauseated. Compazine 10mg IM Pt continues to feel nauseated. Compazine 10mg IM given in R ventrogluteal. -----------------given in R ventrogluteal. -----------------MMacNeilMMacNeil RN RN

11/26/9711/26/97 23352335 Pt states she is no longer nauseated, remains pain Pt states she is no longer nauseated, remains pain free. No further vomiting.-----------------free. No further vomiting.-----------------MMacNeilMMacNeil RN RN

Focus ChartingFocus Charting

Organized into client centered topics.Organized into client centered topics. Encourages use of assessment data to evaluate Encourages use of assessment data to evaluate

these concernsthese concerns Works best on acute care settingsWorks best on acute care settings Typically write each focus as Typically write each focus as

a nursing diagnosis (ie risk for infection) a nursing diagnosis (ie risk for infection) a sign or symptom (ie chest pain)a sign or symptom (ie chest pain) a patient behavior (ie. unable to ambulate)a patient behavior (ie. unable to ambulate) an acute change in the clients condition (ie. loss of an acute change in the clients condition (ie. loss of

consciousness)consciousness) or a significant event (ie. surgery)or a significant event (ie. surgery)

In the progress notes, divide information into 3 In the progress notes, divide information into 3 categories; data (D), action (A), and response categories; data (D), action (A), and response (R)(R)

DataData – include subjective & objective info that – include subjective & objective info that describes the focusdescribes the focus

ActionAction – include immediate & future nursing – include immediate & future nursing actions based on your assessment of the clients actions based on your assessment of the clients condition. The category also includes changes condition. The category also includes changes to the plan of careto the plan of care

ResponseResponse – describes the clients response to – describes the clients response to nursing or medical carenursing or medical care

Continue to record routine nursing tasks on Continue to record routine nursing tasks on flowsheets & checklistsflowsheets & checklists

Pros of Focus ChartingPros of Focus Charting

Flexible enough to adapt to any clinical Flexible enough to adapt to any clinical settingsetting

Centers on the nursing processCenters on the nursing process Information on a specific problem is easy Information on a specific problem is easy

to findto find Encourages regular documentation of Encourages regular documentation of

patient responsespatient responses Helps to organize your thoughts & Helps to organize your thoughts &

document succinctly & preciselydocument succinctly & precisely

Cons of Focus ChartingCons of Focus Charting

Staff may need in-depth training if they are Staff may need in-depth training if they are used to charting with another systemused to charting with another system

Need to use many flowsheets & Need to use many flowsheets & checklists, which can lead to inconsistent checklists, which can lead to inconsistent documentationdocumentation

If you forget to include the patient’s If you forget to include the patient’s response to interventions, focus charting response to interventions, focus charting resembles a long narrativeresembles a long narrative

Sample of Focus ChartingSample of Focus ChartingDateDate TimeTime FocusFocus Progress NotesProgress Notes

8/3/978/3/97 10001000 Knowledge Knowledge deficit r/t deficit r/t diagnosisdiagnosis

D:D: Pt states she does not understand what Pt states she does not understand what her diagnosis meansher diagnosis means

A:A: Illness explained to pt according to her Illness explained to pt according to her level of understanding. Pt taught symptoms level of understanding. Pt taught symptoms she may expect and why she is having she may expect and why she is having current symptoms. Treatments and current symptoms. Treatments and procedures explainedprocedures explained

R:R: Pt verbalized better understanding of her Pt verbalized better understanding of her illness. ----------------------------illness. ----------------------------MMacNeilMMacNeil RN RN

8/3/978/3/97 10001000 Anxiety Anxiety D:D: Pt states “I’m afraid of all this blood”. Pt states “I’m afraid of all this blood”.

A:A: Emotional support provided. Encouraged Emotional support provided. Encouraged verbalizations. Explanations given regarding verbalizations. Explanations given regarding treatments and procedures. Family in to treatments and procedures. Family in to provide support.provide support.

R:R: Pt observed talking and laughing with Pt observed talking and laughing with family. States she feels less anxious. -------family. States she feels less anxious. -------

------------------------------------------------------------------------------MMacNeilMMacNeil RN RN

Computerized ChartingComputerized Charting

Reduces time spent on documentation & Reduces time spent on documentation & increases accuracyincreases accuracy

Helps identify client education needsHelps identify client education needs Supplies data for nursing research & Supplies data for nursing research &

educationeducation Each person would have their own Each person would have their own

computer ID number. These codes help computer ID number. These codes help maintain client’s privacymaintain client’s privacy

Pros of Computerized ChartingPros of Computerized Charting

Storing & retrieval of information is fast & Storing & retrieval of information is fast & easyeasy

Can constantly update informationCan constantly update information Uses standard terminology, which Uses standard terminology, which

improves communication among HCPimproves communication among HCP Always legibleAlways legible Can send request slips & client information Can send request slips & client information

from one terminal to another quickly & from one terminal to another quickly & efficiently which helps ensure efficiently which helps ensure confidentialityconfidentiality

Cons of Computerized ChartingCons of Computerized Charting

If security measures are neglected, can threaten If security measures are neglected, can threaten client confidentialityclient confidentiality

Standardized phrases & limited vocabulary can Standardized phrases & limited vocabulary can make information inaccurate or incompletemake information inaccurate or incomplete

Some people have trouble adjusting to Some people have trouble adjusting to computerscomputers

Charting can take extra time if too many nurses Charting can take extra time if too many nurses try to chart on too few terminalstry to chart on too few terminals

Expensive to initially establish the system Expensive to initially establish the system

NSHISNSHIS

Nova Scotia Hospital Information SystemNova Scotia Hospital Information System Across the province, except Capital Health Across the province, except Capital Health

(Halifax)(Halifax) One of the many components is the care plan. One of the many components is the care plan.

From the care plan comes the interventions, From the care plan comes the interventions, assessment screens, outcomes.assessment screens, outcomes.

Nurses notes used minimally. Use mainly Nurses notes used minimally. Use mainly checklists. If notes are used, they are written checklists. If notes are used, they are written using focus charting format. Start with a focus & using focus charting format. Start with a focus & link the notes to the appropriate assessment.link the notes to the appropriate assessment.

Accurate, detailed charting shows Accurate, detailed charting shows the extent & quality of care you’ve the extent & quality of care you’ve

provided, the outcome of that provided, the outcome of that care, & treatment and education care, & treatment and education

that the patient still needs.that the patient still needs.