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Documentation NURS 232

What is CHARTING or DOCUMENTING? The process of making an entry on a client record.
Narrative Charting a traditional part of the source-oriented record. consist of routine notes that include routine care, normal findings, and client problems.
What should documentation for each encounter with the client include? ¤ reason for encounter and relevant history ¤ Assessment findings ¤ Plan of care ¤ Date and legible signature of all providers
What should you do prior to charting make sure you have the right record.
Should you leave any spaces before entries or your signature? No.
How do you correct an error on a paper chart? Draw a single line through the error and then date and initial
when charting clients remarks what should you do? use quotations.
Should you chart other nurses or health care staff observations about your client/patient? No, chart only your own observations.
Can you alter an entry for someone else? No, never alter an entry for another person; contact the individual.
what color ink should you use when charting? Black
Can you chart something before you have done it? No; this can be considered fraudulent. Always chart after you have done the action never before.
what abbreviations can you use when charting? only approved abbreviations follow agency p/p.
What is charting by exclusion ¤ Usually accomplished by “charting by exception” ¤ Standardized questions are asked, but client responses in the negative are not recorded
What does charting by exclusion assume? Assumes all is well unless something is noted.
What is charting by exclusion based on? clearly defined standards and criteria.
What is Flowsheet charting used for? Used to document specific assessment criteria in an particular format ¤ For example, vital signs, pain intensity scores, intake and output
What does PIE stand for? Plan Implement Evaluate
What does SOAP(IE) stand for? Subjective Objective Assessment Plan Intervene Evaluate
What does DAR stand for? Data Action Response
What is a shift report? ¨ Nurse to nurse report when providers change ¨ Nurse to nurse report at change of shift (most facilities have standardized method) ¨ Nurse to provider report for change of condition or for instruction.
What patient data are you allowed to access? only the information you need to do you job
What are the purposes of the client record? Communication Planning payment care auditing health agencies research education reimbursement Legal documentation Health care analysis
Created by: 1390023652