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CHARTING

USES FOR THE MEDI CAL RECORD


PERMANENT ACCOUNT

TRACKS PT
PROGRESS/CARE GIVEN

SHARING INFORMATION

PATIENT
CONFIDENTIALITY

QUALITY ASSURANCE

ACCREDITATION

6 ITEMS THAT MUST BE
DOCUMENTED

INSURANCE
REIMBURSEMENT

RESEARCH

LEGAL EVIDENCE FOR
MALPRACTICE SUITS

ASSURES CONTINUITY OF
CARE


USES FOR THE MEDICAL RECORD
PERMANENT RECORD

WRITTEN IN CHRONOLOGICAL
ORDER

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.

FOLLOW YOUR FACILITIES POLICY.

DO NOT ALTER CHARTING, IT IS A LEGAL DOCUMENT.