Transcript Documentation! - Bakersfield College

Documentation!
Documentation and Reports
• Communicate information about
clients healthcare needs
• Ensures that all goals and
interventions are directed towards
same goal
Report vs. Record
• Report
– Oral or written
– Between staff, other health
professionals, lab reports
• Record
– Permanent written communication
– Legal part of chart
Guidelines for Good
Charting
• Fact
– Stick to them
– Descriptive/objective
– Vague
– Response to medications
– Clients own words
• Accuracy
–I & O
– Wound size
– Wound length
– Abbreviations
– Correct spelling!!!
– Don’t chart for others
– Sign name, no nicknames
• Concise
– Playing vs. running, laughing
• Current
– Delays in reporting can result in delay of
treatment
– Delay can be interpreted as negligence
– Report ASAP
– Bed baths, I & O don’t have to be
immediate but in timely manner
– Keep notepad in pocket
– Know military time!
• Organization
– Chart in order things occurred
• Confidentiality
– All patient info is CONDIFENTIAL!!
Common Types of Reporting
• Change of shift
– Oral, recorded, during rounds
– Report quickly and efficiantly
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Health status
Kind of care required
Changes in therapy
Behavior changes
Allergies
Nursing intervention results
IV and meds
Don’t label grumpy, mean
Common Types of Reporting
• Telephone
• Transfer reports
• Incident reports
– Not part of the chart
– Used when something abnormal
happens
Documentation
• Purposes
– Communicate info to health care team
– Keep track of interventions and goals
• Legal guidelines–Table 25-1 pg. 480
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Always use ink
Always sign your name
Never destroy charting or mark through it
Time and date notes
If you did not chart it, it never happened!!!
Methods of Documentation
• Problem oriented medical record
– Places emphasis on problems
– Organized by problems
– Compiled of
• Data base
• Problem list
• Care plan
• Progress notes
• Modified problem oriented
• Source records
• Charting by exception
– Eliminates redundancy
– Makes it concise
– Easy to document normal findings
– Critical for nurses to chart abnormal!
• Focus charting
• Case management plan and critical
pathways
– Incorporates multidisciplinary approach
– Broken down into critical pathways
Other Record Keeping Forms
• Nursing History
– Completed when a client is admitted
– Complete assessment
– Provides baseline data
• Graphic sheets
– Allows doctors and nurses to easily and quickly
enter data
– Vital signs
– Routine care
– Have codes to enter data
• Standardized care plans
– Pre-printed guidelines for patients with
similar problems
• Discharge summary forms
– Discharge planning begins on admission
– Education on medications
– Summarized patient instructions for
home
• Nursing kardex
• Computerized documentation
– Advantages
– Disadvantages