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Is a legal record that is used to meet the many demands of the health, accreditation, medical insurance, and legal systems.
* the process of adding written info to the chart is called charting, recording, or documenting.
* Documentation is part of the implementation phase & is necessary for the evaluation of patient care as well as cost reimbursement.
* Good documentation reflect the nursing process.
* When charting interventions document the type, time of care, & signature of person providing care.
There are five basic purposes for written patient record
- Written communication
- Permanent record for accountability
- legal record of care
- research and data collection
People appointed to examine patients charts & health records to assess quality of care
An appraisal by professional co-workers of equal status
AN audit in health care that evaluates services provided and the results achieved compared with accepted standards.
Diagnosis Related Groups (DRGs)
A system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay. Basis cost reimbursement plans (Medicare, Medicaid)
The form on the patients chart on which nurses record their observations, care given, and patients responses.
* Patient health records are also used for teaching. Individuals involve din research and data collection in the health field have many uses for patient records.
* A nurse can't effectively & efficiently use a health record until some understanding and knowledge of common abbreviations & medical terms have been developed.
*Most facilities have published lists of generally accepted medical abbreviations and terms approved for use in charting.
Traditional Chart (block)
Is divided into sections or blocks. Emphasis is placed on specific sheets of info. Typical sections are admission sheet, physicians orders, progress notes, history & physical examination data, care plan...
Recording of patient care in descriptive form. Includes the basic patient need or problem data, whether someone was contacted, care & treatments provided, and patients response to treatment.
Problem oriented medical record (POMR)
Is based on the scientific problem solving system or method. Principle sections are database, problem list, care plan, and progress notes. The accumulated data, from the history, physical examination, & diagnostic tests are used to identify & prioritize the health problems. SOAPIER used.
Serves as the index for chart documentation. All health care providers chart on same progress notes.
* Narrative notes, flow sheets, & discharge summaried are forms used to document patient progress.
SOAPIER (SOAPE documentation) (arose from medical model)
- AN acronym for seven different aspects of charting.
- S - Subjective
- O- Objective
- A - Assessment - cause of patients problem
- P - Plan - plan of care
- I - Intervention/Implementation - care or action taken
- E- Evaluation - appraisal of response & effectiveness
- R - Revision - includes change that may be made to original plan of care
Focus Charting Format
Another charting form used. A modified nursing diagnoses is used as an index for nursing documentation. Focuses on patient needs rather than medical diagnoses. DARE used as acronym.
- D - Data
- A - Action
- R - Response/evaluation
- E - Education/patient teaching
* The quality & accuracy of the nurses notes are extremely important.
* Each institutions policy should be followed.
* Nurses notes should always correlate with the medical orders, Kardex, & nursing care plan.
* RN has primary responsibility for patients initial admission nursing history, physical assessment, & development of the care plan.
* Some facilities require a minimum of 3 entries per shift made on narrative notes.
Charting By Exception (CBE)
- Complete physical assessments, observations, vital signs, IV site & rate, and other pertinent data are charted at the beginning of each shift. Flow sheet is used with this. PIE format can be used. (Arose from nursing process)
- P - PROBLEM
- I - INTERVENTION
- E - Evaluation
- Sometimes an A is addes before the P for assessment data
*Charting rules were developed to provide consistency in documentation between health care providers and facilities.
Four common issues in malpractice caused by inadequate documentation
- Not charting the correct time when events occured
- failing to record verbal orders or failing to have them signed
- charting actions in advance to save time
- documenting incorrect data
A card systemused to consolidate patient orders and care needs in a centralized, concise way.
Any event not consistent with the routine operation of a health care unit or the routine care of a patient. List date, time, care given, patient, and name of physician notified. When charting the incident in patients nurse's notes don't mention the incident report because this makes it easier for attorney to request document for court case.
A rating score that rates the patient by severity of illness, requires staff to document their interventions and thereby obtain an overall level of acuity for each patient.
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