Documentation

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Documentation

• NUR 869

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Client Record

• A permanent legal documentation of information
  relevant to clients health care management.

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Purpose of the record

• Communication between team members
• Financial Billing
• Education
• Assessment
• Research
• Auditing
• Legal Documentation

4

• CARE NOT
• DOCUMENTED IS CARE NOT DONE.

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Common problems in malpractice

1. Not charting correct time events occurred
2. Failing to record verbal orders or have them
   signed
3. Charting in advance to save time
4. Documenting incorrect data

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• We are legally and ethically obligated to keep
  client information confidential.

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• The client can read records with written release
  of information.

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Components of client record

• 1. Information sheet
• 2. Graphic sheet
• 3. Physicians order sheet
• 4. Progress notes
• 5. Flow sheets
• 6. Consult sheet

• 7. Laboratory results
• 8. Consent Form
• 9. Medication Records
• 10.Special Records
• 11.Discharge Summary

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Guidelines for documentation and reporting

• Factual
• Accurate
• Complete
• Current
• Organized
• Confidentiality

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• CONFIDENTIALITY

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Methods of Documentation

• SOAP notes
• DAR

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Charting Bloopers

• Skin Somewhat pale but present.
• The pelvic exam will be done on the floor.
• She was treated with Mycostatin oral
  suppositories.
• By the time she was admitted to the hospital her
  rapid heart had stopped and she was feeling much
  better.