Documentation NURS 232
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| What is CHARTING or DOCUMENTING? | The process of making an entry on a client record.
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| Narrative Charting | a traditional part of the source-oriented record. consist of routine notes that include routine care, normal findings, and client problems.
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| 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
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| What should you do prior to charting | make sure you have the right record.
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| Should you leave any spaces before entries or your signature? | No.
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| How do you correct an error on a paper chart? | Draw a single line through the error and then date and initial
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| when charting clients remarks what should you do? | use quotations.
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| Should you chart other nurses or health care staff observations about your client/patient? | No, chart only your own observations.
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| Can you alter an entry for someone else? | No, never alter an entry for another person; contact the individual.
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| what color ink should you use when charting? | Black
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| 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.
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| what abbreviations can you use when charting? | only approved abbreviations follow agency p/p.
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| What is charting by exclusion | ¤ Usually accomplished by “charting by exception”
¤ Standardized questions are asked, but client responses
in the negative are not recorded
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| What does charting by exclusion assume? | Assumes all is well unless something is noted.
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| What is charting by exclusion based on? | clearly defined standards and criteria.
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| 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
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| What does PIE stand for? | Plan
Implement
Evaluate
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| What does SOAP(IE) stand for? | Subjective
Objective
Assessment
Plan
Intervene
Evaluate
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| What does DAR stand for? | Data
Action
Response
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| 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.
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| What patient data are you allowed to access? | only the information you need to do you job
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| What are the purposes of the client record? | Communication
Planning payment care
auditing health agencies
research
education
reimbursement
Legal documentation
Health care analysis
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