CHARTING

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CHARTING

• Documentation
• NS 101
• Spring 2005
• Developed by Nancy Hoverman
• Revised by Vickie Beatty 2005

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Content Overview

• Goals of Documentation
• Key Components of Documentation
• Charting Dos and Donts
• Legal Implications
• Types of Nursing Progress Notes
• Narrative
• PIE
• Soap
• DART
• Computer charting
• End of Shift Report
• Patient Discharge Instructions

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Confidentiality
CONFIDENTIAL
CONFIDENTIAL
CONFIDENTIAL
CONFIDENTIAL
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Goals of Documentation

• Improve the quality of patient care. (Auditing)
• Ensure documentation of progress with regard to
  patient focused outcomes.
• Interdisciplinary communication.
• Present an accurate picture of patient throughout
  the time of being in the health care system.
• Financial Billing
• Research and Education

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Functions of Nurses' Progress Notes

• Facilitating patient care
• Legal documentation
• Evaluation/ Nursing Audit
• Training and supervision
• Reimbursement
• Accreditation -- JACHO

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Key components of nursing documentation

• Assessments A
• Identified patient needs D
• Planned care P
• Revisions of planned care
• Nursing interventions I
• Patient teaching
• Patient outcomes E

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Essential information to chart

• Any behavior changes or changes in consciousness
• Any changes in physical functions

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Essential information to chart

• Any physical sign or symptom that is severe,
  recurs or persists, abnormal, increases,
  indicates a complication, is not relieved by
  prescribed measures, is a known danger signal or
  is a sign of faulty health habits.

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Essential information to chart

• Nursing interventions provided
• Visits by physician or other members of the
  health team
• Any transfer of patient from one area to another
  and reason

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Essential information to chart

• Address problems related to the patients
  diagnosis and problems identified in the
  patients care plan!
• Any unexpected change in the patients condition.

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Charting DOs

• Read prior nursing notes
• Be concise
• Document action taken
• Sign each entry
• Be definite
• Have patients name and identifying number on
  every sheet

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Charting DOs

• Be accurate and factual
• Use legible writing and correct spelling
• Use only accepted hospital abbreviations

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Charting DOs

• Date and time each entry. Should be consecutive
  when possible. If you must make a late entry
  (not consecutive), chart the time you are making
  the entry and identify it as late entry.
• Use nonjudgmental language
• REFER TO THE PATIENT BY NAME!

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3/9/04 1500 D. Late entry for 3/9/04, 1200. Mr. J
had emesis of 250cc coffee ground colored
liquid. BP 100/76,P 90,R 20. Denied any gastric
distress. Instructed not to take any more food
or fluids until his physician was notified. E.
Ancheta, RN-----------------------------
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Charting Dos

• Do not erase, use correction fluid
• Do not write retaliatory or critical comments
• Correct all errors promptly
• Record all facts
• Do not leave blank spaces
• Table 25-1 page 480 Potter and Perry, Legal
  Guidelines for Recording

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Charting Dos

• Record all entries legibly and in black ink
• If an order questioned, record that clarification
  was sought
• Chart only for your self.
• Avoid empty phrases like had a good day
• Begin each entry with time and date and end with
  your signature and title
• Keep any computer passwords secure
• Potter and Perry, page 480

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Charting DONTs

• Begin charting before checking the name on the
  patients chart
• Skip lines or space
• Chart in advance
• Wait until the end of the shift to chart
• Erase, obliterate, alter or destroy. Draw a
  single line through errors and identify as error
  in charting followed by your initials.

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Charting DONTs

• Use medical terms incorrectly
• Backdate, tamper with or add to notes. (Use an
  addendum if necessary. See late entry on DOs)
• Repeat in your narrative what you have written on
  forms in other parts of the chart unless it adds
  to clarity or further explanations are needed.

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NARRATIVE CHARTING

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• 9-6-04 0800 Mr. Jones c/o indigestion and
  burning sensation in epigastric area. Skin
  warm/dry, color pink, vital signs unchanged.
  Given Mylanta 30 ml po. Head of bed elevated 15
  degree. ------------------------E. Ancheta, RN
• 0830 States pain relieved. Lying quietly in
  bed. ------------------E. Ancheta, RN

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PIE CHARTING

• Problem
• Intervention
• Evaluation

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• 9-6-04 0800 1 Pain P Pain 5/10 heartburn
  in epigastric area.
• I Medicated c 30 cc Mylanta and
  elevated head of bed to 45
  degrees. -E. Ancheta, RN
• 0900 E States relief from pain to
  2/10----- E. Ancheta, RN

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SOAP/ SOAPE/ SOAPIE CHARTING

• S ubjective S ubjective S ubjective
• O bjective O bjective O bjective
• A ssessment A ssessment A ssessment
• P lan P lan P lan
• E valuation I ntervention
• E valuation

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• 9-6-04
• 0800 1 Pain S Mr. Jones c/o heartburn, a
  dull, burning sensation in upper
  abdomen.
• O Grimacing, leaning forward and
  holding hand against epigastric area.
• A Pain R/T reflux gastric
  secretions.
• P Administer Mylanta 30cc po as
  ordered. Head of bed elevated 45
  degrees.
• -------E. Ancheta, RN
• 0900 1 Pain E States pain relieved to
  2/10 level.
• ------------------E. Ancheta, RN

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DART CHARTINGData Action ResponseTeaching

• AKAFOCUS CHARTING

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Elements of Focus Charting

• Focus Subject
• Data Subjective/Objective assessments
• Action What I did
• Response Did it work?
• Teaching Patient Education r/t subject

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• 7-6-04
• 0800 Gastric Distress
• D. Awakened, c/o indigestion and
  burning sensation in epigastric area.
  Abdomen soft.
• Skin warm/dry, color pink, vital
  signs unchanged.
• A Given Mylanta 30 ml po.
  Head of bed elevated 15degrees.
• R Reports pain relieved. Lying
  quietly in bed.
• T. Discussed low acidic food
  choices. Handout given.
• --E. Ancheta, RN

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Scenario

• A 60 year old diabetic client was admitted due to
  a fall in which he bumped his head. Up until this
  time all vitals, neuros, etc. were within normal
  limits. At 2200 the following was noted Diabetic
  flow sheet-Accucheck 300, Neuro Record- PERL,
  drowsy, Left hand grasp weaker than right, Health
  team record- inappropriate words lethargic
  confused, VS-160/90-68-12- 99.2, orally. The
  nurse informed the MD of the changes, orders were
  received.
• Write a focus note based of the above information

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Charting by Exception
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Use of Computers in Documentation
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Advantages

• Enhanced data management and communication
• Enhanced teaching of patient care management
• Enhanced development of protocols
• Increased systematic approach to patient care

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Practical Advantages

• Legibility
• Accuracy
• Timely data
• Rapid communication
• Definite document accountability
• Enhanced patient education
• Reduced medication errors

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Disadvantages

• Malfunction
• Impersonal effect
• Concern for privacy
• Dissemination of inaccurate information
• Limitation of standard vocabulary
• Cost
• Privacy

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Types of computerized records

• History and assessment
• Care Plan (uses NANDA diagnosis)
• Nursing notes
• Medication sheets

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Verbal Reporting
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End of Shift Report

• Purpose
• Relay information
• Provide continuity of care

• Different ways
• Oral report
• Audiotape recording
• Walking rounds
• Written
• Second hand

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What to include

• Basic identifying background information Name,
  room number, age, medical dx, admission date,
  physician (pertinent BCFs)
• Description of the patients present condition --
  only significant data (assessments)
• Significant changes in the patients condition
• Progress in goal achievement for identified
  nursing diagnoses (SCD, SCL)
• Discharge Plan

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What to include (cont)

• Pertinent results of diagnostic tests or other
  therapies performed in the last 24 hours
• Significant emotional responses (include family
  interactions)

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What to include (cont)

• Description of invasive lines, pumps, and other
  apparatus
• Description of important activities that occurred
  on your shift (teaching plan)
• Description of care the on-coming nurse needs to
  do (priority needs

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What Not To Include

• Idle gossip, opinion
• Critical comments about clients behavior
• Details of routine procedures
• Repetitive information

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At 1215 Mr. Jones has his light on. You enter
his room. His hands are clenched and his muscles
are tense. He tells you he has a dull throbbing
pain in his left foot. He further states when
asked that it does not radiate up his leg. Mr.
Jones diagnosis is cellulitis of the left foot.
His foot is red and swollen but appears the same
as it did when you assessed it at 0700. His toes
are warm to touch his toenails blanch when
pressed and the color returns immediately. You
order a foot cradle for his bed and give him
Darvon 65 mg po. You return to his room at 1245
and place the foot cradle on his bed. He says
his pain is not gone but it is now 3 and you
note that he appears relaxed.
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• 1215 C/O dull throbbing pain in L foot.States
  doesnt radiate up leg. Hands clenched and
  muscles tense. L foot red and swollen but
  unchanged since 0700.Toes warm, toenails blanch
  with immediate capillary refill. Medicated with
  Darvon.---------P. Brady RN
• 1245 Foot cradle placed on bed. States pain
  now 3/10 on scale of. --------- P. Brady, RN

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• 1215 1Pain. P Hands clenched. States
  dull throbbing pain in left foot.
  Doesnt radiate up leg. Foot red and
  swollen but unchanged since 0700. Toes
  warm to touch, toenails blanch with
  immediate capillary refill.
• I Medicated for pain. Foot
  cradle ordered. P. Brady RN
• 1245 1Pain. I Foot cradle placed on bed
• E States pain is now 3/10.
• -----------------P. Brady, RN

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• 1215 Pain D C/O dull throbbing pain in L
  foot. Hands clenched, muscles tense.
  States pain does not radiate up let. L foot
  red and swollen but unchanged since 0700. Toes
  warm, toenails blanch, immediate capillary
  refill.
• A Foot cradle ordered. Medicated
  for pain. ------------P. Brady,RN
• 1245 Pain A Foot cradle placed on bed.
• R States pain now
  3/10 ---------------P. Brady, RN

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• 1215 1Pain S States dull throbbing pain in L
  foot that does not radiate up leg.
• O Hands clenched, muscles tense. L
  foot red, swollen,but appears unchanged since
  0700. Toes warm to touch, toenails blanch
  with immediate capillary refill. A
  Pain related to cellulitis. Condition
  changed.
• P To medicate with Darvon and place
  footboard on bed.
• 1245 1Pain E. States pain 3/10. P. Brady, RN

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Charting your assessment

• (See handout)

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• Mr. Jones opens eyes when addressed, no
  verbal response. Pupils equal, dilated 4 mm,
  slight response to light. Hand grasps weak,
  slightly stronger on right side. Does not push
  with feet when asked.
• Breath sounds clear all lobes, diminished on
  R side. O2 per nasal cannula _at_ 2 l/min. AP 54,
  regular. Peripheral pulses weak but palpable X 4.
  
• Feet cool to touch, nailbeds pale. Skin warm,
  dry, intact without redness or edema.
• Bowel sounds present X4, hypoactive. Abdomen
  soft.
• Foley draining dark yellow urine, mucus strings
  in tubing.
• D5LR _at_ 125cc/hr in L forearm, area slightly red
  and swollen. IV discontinued. To be restarted
  in alternate site. Condition remains unchanged
  at this time. Will continue current care plan.
  ---------------P. Brady, RN

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Charting Procedure Summary

• Identify relevant information to record
• Identify where to document
• Do a final check
• Legibility
• Factual
• Completeness
• Accurate
• Correct format
• Organized
• Current with date, time, signature

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THATS ALL FOLKS