CHARTING

USES FOR THE MEDICAL RECORD

PERMANENT ACCOUNT
TRACKS PT PROGRESS/CARE GIVEN

6 ITEMS THAT MUST BE DOCUMENTED

INSURANCE REIMBURSEMENT RESEARCH LEGAL EVIDENCE FOR

SHARING INFORMATION
PATIENT CONFIDENTIALITY

QUALITY ASSURANCE
ACCREDITATION

MALPRACTICE SUITS
ASSURES CONTINUITY OF CARE

USES FOR THE MEDICAL RECORD

PERMANENT RECORD
WRITTEN IN CHRONOLOGICAL

ORDER
FILED IN MEDICAL RECORDS DEPT

FOR FUTURE USE/REFERENCE

USES FOR THE MEDICAL RECORD

SHARING INFORMATION
FACILITATES EXCHANGE OF

INFORMATION BETWEEN STAFF

PREVENTS DUPLICATION ERRORS
(MEDS, DRESSING CHANGE, ACTIVITY, DIETS, ETC.)

USES FOR THE MEDICAL RECORD

PATIENT CONFIDENTIALITY
NEVER LEAVE CHART IN A PUBLIC PLACE. DISCUSS CONTENTS ONLY WITH PERSONS

DIRECTLY INVOLVED IN THE PATIENTS CARE OR THOSE THAT ARE AUTHORIZED BY THE PATIENT. THESE PEOPLE SHOULD BE LISTED BY NAME. ASK FOR ID PRIOR. DO NOT DISCUSS PT OR PT INFO IN PUBLIC PLACES, EG. ELEVATORS, CAFTERIA.

USES FOR THE MEDICAL RECORD

QUALITY ASSURANCE
A PEER REVIEW PROCESS

CONDUCTED BY A STAFF NURSE AND PHYSICIAN ESTABLISHES AND REFLECTS AGENCY STANDARDS

USES FOR THE MEDICAL RECORD

ACCREDITATION
JCAHO (JOINT COMMISSION ON ACCREDITATION OF HEALTH ORGANIZATION)/DSHS STATE (EXTENDED CARE) SETS MINIMUM STANDARDS FOR STAFFING THE AMERICAN NURSES ASSOCIATION SETS THE STANDARDS FOR PT CARE & DOCUMENTATION FOR NURSES

USES FOR THE MEDICAL RECORD

SIX ITEMS THAT NURSES MUST

DOCUMENT
ASSESSMENT NURSG DX AND PT NEEDS INTERVENTIONS CARE PROVIDED PT RESPONSE TO CARE PTS ABILITY TO MANAGE CONTINUING CARE AFTER DISCHARGE

USES FOR THE MEDICAL RECORD

REIMBURSEMENT
LACK OF DOCUMENTATION MAY

RESULT IN DENIAL FOR PAYMENTS FROM MEDICARE AND PRIVATE INSURANCE COMPANIES. THIS PUTS THE BURDEN OF PAYMENT ON THE PATIENT.

USES FOR THE MEDICAL RECORD

RESEARCH
DATA ON TREATMENTS, MEDS, AND THERAPY

INFO FOR TUMOR BOARDS, DOCTORS ROUNDS, NURSING ROUNDS, ETC.

BE AWARE OF PRIVACY ISSUES

NURSES, STUDENT NURSES USE FOR CARE PLANS.

USES FOR THE MEDICAL RECORD

LEGAL EVIDENCE
RECORDS ARE CONSIDERED LEGAL OR

POTENTIAL LEGAL DOCUMENTS MAY BE SUBPEONAED AS EVIDENCE BY ATTORNEY OR NURSING BOARDS. CHECK FOR DEVIATIONS FROM FACILITY POLICY OR STANDARDS. EACH HEALTH CARE PROVIDER IS RESPONSIBLE FOR THE ABCS OF RECORDING. ACCURACY, BRIEF, COMPLETE.

ACCESS TO CHARTS
PATIENTS RIGHTS
WHO OWNS

CHART
AGENCY POLICY

ACCESS TO CHARTS
PATIENTS RIGHTS/AGENCY POLICY
PATIENTS HAVE THE RIGHT TO THE INFO

IN THEIR CHARTS. THEY DO NOT HAVE THE RIGHT TO SEE THE CHART ON DEMAND OR REMOVE ANYTHING FROM THE CHART, OR REMOVE THE CHART FROM THE FACILITY.

ACCESS TO CHARTS
WHO OWNS THE CHART
A PATIENTS CHART IS THE

PROPERTY OF THE FACILITY. IT IS THE FACILITY WHICH SETS THE POLICY AND MAKES APPOINTMENTS FOR VIEWING OF THE CHART.

TYPES OF PATIENT RECORDS

SOURCE-ORIENTED

PROBLEM-ORIENTED

TYPES OF PATIENT RECORDS

SOURCE ORIENTED
MOST TRADITIONAL DIFFERENT DISCIPLINES CHART ON

SEPARATE FORMS. EACH READER MUST CONSULT VARIOUS PARTS OF THE RECORD TO GET A COMPLETE PICTURE. RECORDS BECOMES BULKY.

TYPES OF PATIENT RECORDS

PROBLEM ORIENTED
COMMONLY REFERRED TO AS POR. ORGANIZED ACCORDING TO PROBLEM. FOUR PARTS:
A. DATA BASE. THE PATIENTS PRESENT HEALTH STATUS. B. PROBLEM LIST. NUMBERED LIST OF HEALTH PROBLEMS. C. INITIAL PLAN. PLAN TO HELP OVERCOME HEALTH PROBLEMS. D. PROGRESS NOTES. ALL DISCIPLINES CHART ON SAME PAGE.

METHODS (STYLES) OF CHARTING

NARRATIVE
SOAP

SOAPIER FOCUS DATA ACTION RESPONSE PIE EXCEPTION CHARTING

NARRATIVE
CHRONOLOGICAL
BASELINE CHARTED QSHIFT LENGTHY, TIME-CONSUMING

SEPARATE PAGES FOR EACH

SOURCE-ORIENTED

SOAP
USED FOR PROBLEM-ORIENTED CHARTS
S SUBJECTIVE. WHAT PT TELLS YOU. 0 OBJECTIVE. WHAT YOU OBSERVE, SEE. A ASSESSMENT. WHAT YOU THINK IS GOING ON

BASED ON YOUR DATA. P PLAN. WHAT YOU ARE GOING TO DO. CAN ADD TO BETTER REFLECT NURSING PROCESS I INTERVENTION (SPECIFIC INTERVENTIONS IMPLEMENTED) E EVALUATION. PT RESPONSE TO INTERVENTIONS. R REVISION. CHANGES IN TREATMENT.

EXAMPLE OF SOAP CHARTING

#1 ALTERATION IN COMFORT. ABDOMINAL

PAIN. S COMPLAINS OF PAIN IN RUQ O IS PALE AND HOLDING RIGHT SIDE A RECURRING ABDOMINAL PAIN P PUT ON NPO AND NOTIFY PHYSICIAN

FOCUS CHARTING
USES NARRATIVE DOCUMENTATION (DAR)
DATA SUBJECTIVE OR OBJECTIVE THAT

SUPPORTS THE FOCUS (CONCERN)

ACTION NURSING INTERVENTION RESPONSE PT RESPONSE TO INTERVENTION

EXAMPLE OF FOCUS CHARTING

D COMPLAINING OF PAIN AT INCISION SITE

ON LEVEL OF #7
A REPOSITIONED FOR COMFORT. DEMEROL

50MG IM GIVEN.
R (CHARTED AT A LATER DATE.) STATES A

DECREASE IN PAIN, FEELS MUCH BETTER.

PIE CHARTING
Similar to SOAP charting
Both are problem-oriented PIE comes from the Nursing Process,

SOAP comes from a Medical Model. P-Problem I-Intervention E-Evaluation

SAMPLE OF PIE CHARTING

P#1 Risk for trauma related to dizziness.
IP#1 Instructed to call for assistance when

getting OOB. Call light in reach.

EP#1 Consistently call for assistance

before getting OOB. Continues to experience dizziness.

CHARTING BY EXCEPTION
USES FLOWSHEETS
EMPHASIS ON ABNORMAL (WHAT IS

ABNORMAL FOR THIS PATIENT.

ALTHOUGH IT MAY BE ABNORMAL FOR THE

NORMAL PERSON, IF IT IS ABNORMAL FOR YOUR PATIENT ON A CONSISTENT BASIS, IT IS NO LONGER CONSIDERED AN EXCEPTION.

ADVANTAGE

COMPUTERIZED CHARTING
PASSWORD. NEVER SHARE. CHANGE FREQUENTLY.
LEGIBLE CAN BE VOICE-ACTIVATED, TOUCH-ACTIVATED. DATE AND TIME AUTOMATICALLY RECORDED.

ABBREVIATIONS AND TERMS ARE SELECTED BY A MENU

PROVIDED BY THE FACILITY. TERMINALS ARE USUALLY EASILY ACCESSIBLE, IN PT ROOMS, CONVENIENT HALLWAY LOCATIONS. MAKE SURE TERMINAL CANNOT BE VIEWED BY UNAUTHORIZED PERSONS.

KARDEX
QUICK REFERENCE CHANGED AS NEEDED

NOT PART OF PERMANENT RECORD

ABBREVIATIONS
YOU MUST USE YOUR FACILITYS

APPROVED ABBREVIATIONS. BE AWARE THAT A LOT OF COMMONLY USED ABBREVIATIONS: EG. TID, BID, QOD, HS ARE NO LONGER ALLOWED AND SHOULD BE CURRENTLY BEING PHASED OUT OF YOUR FACILITY.

CHANGE OF SHIFT REPORT

PERSON TO PERSON

BE PREPARED
AVOID GOSSIP/SOCIALIZA

TION TAPE RECORDER

INCIDENT REPORTS
OBJECTIVE
DO NOT BLAME OR

ADMIT LIABILITY WHAT DID YOU DO? DO NOT INCLUDE NAMES/ADDRESSES OF WITNESSES DOCUMENT TIME/NAME OF DOCTOR DO NOT FILE IN CHART DO NOT WRITE INCIDENT REPORT MADE

CORRECTING ERRORS
IF YOU SPILL SOMETHING ON THE CHART, DO NOT

DISCARD NOTES. RECOPY, PUT ORIGINAL AND COPIED SHEETS IN CHART. WRITE COPIED ON COPY.
DO NOT SCRIBBLE OUT CHARTING. AVOID USING ERROR OR WRONG PATIENT WHEN

MAKING CORRECTION.
FOLLOW YOUR FACILITIES POLICY.
DO NOT ALTER CHARTING, IT IS A LEGAL DOCUMENT.