Daily Diary Instructions

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					                     Basic Rules of Charting Information Sheet                              1
Name: _________________________                   Block: ___________

Instructor: J. Kirkland, RN, BSN                  Class: Intro to HSTE

Introduction: Charting presents a written picture of occurrences and situations
pertaining to the patient. All records are strictly confidential and are not to be read or
discussed by anyone except the physician or persons directly caring for the patient
in a healthcare setting. Viewed from a legal standpoint, charting is one of the most
significant duties that a healthcare provider performs. The Assistant or Technician
level healthcare provider may be allowed to use subjective information. Below you
will read the basic rules of charting. Suggestions for how a particular rule is to be
adapted for your Daily Diary entries are in parenthesis.

   1. Entries on the patient’s chart should be legibly printed or handwritten. Many
      facilities are using word processors, but you may be working in Home Health
      or a Long Term Care Facility. These facilities are not likely to have
      computerized documentation programs. After documenting the account, sign
      the chart with your first initial, last name, and your healthcare title. You are
      currently a Healthcare Science Student (HSS). Therefore, your title is HSS.
      (An example of how you will sign off your Daily Entry: M. Smith, HSS)

   2. Ditto marks, white out, erasures, and blacking out with a marker are never
      acceptable ways of correcting an error. If a mistake is made, draw one line
      through the mistake, write “ERROR” above the mistake, initial it, and then
      correct the mistake. If a patient sues the healthcare facility, their chart will be
      brought to court. If the original error cannot be read, the plaintiff’s attorney
      can argue that the facility encourages “falsifying” documents. Your mistake
      may only be a spelling error, but if the original entry cannot be read then you
      are inviting problems in a court case. (Look at your Rubric Checklist and
      you will see that points are deducted from your Daily Diary Grade if you
      do not correct a mistake properly.)

   3. Record after completing each task for the patient and sign your name after
      each entry. Never chart in anticipation of an event happening to the patient or
      before a task is performed. Delays and changes in healthcare are routine, so
      you can never be sure that a task will be performed as expected. (Therefore,
      you should write your Daily Diary entry at the end of the class period.)

   4. Be exact in noting time, effect, and results of all treatments and procedures.
      Record all of your observations, procedures, patient’s reactions, complaints,
      and behavior. Describe type, location, onset, duration, and severity of pain.
      To judge the severity, ask the patient to use a scare of 0 – 10. Zero
      represents no pain and ten represents the most sever pain they can imagine.
      (For your Daily Diary entry, this rule just means to be as thorough as
      you can be with the space provided.)


   5. Note the time of a physician’s visit, examination, and treatments. (For your
      Daily Diary entries, describe visits from guest speakers and other
      visitors to the classroom.)
                    Basic Rules of Charting Information Sheet                                    2
6. Leave no blank lines in the charting. To prevent blanks, sign off at the end of
   your entry. You are not responsible for blanks to the right of your name. The
   next healthcare provider coming on duty after you will begin their entries
   where you signed off. If there is a blank, draw a line through the center of a
   blank line or part of a line. This prevents charting by someone else in an area
   signed off by your. If blank lines are present in a chart, attorneys in a lawsuit
   can argue that the facility encourages blank lines to facilitate falsifying the
   document. (Signing off at the end of your Daily Diary entry will eliminate
   a blank space to the left of your name.
   For example: Dr. Jones was a guest speaker for our class today. The
   topic was legal aspects of charting. He was interesting and I learned
   how important charting is. M. Smith, HSS
   An example of when you would have to draw a line through a blank
   space may look like the following: Dr. Jones was a guest speaker for
   our class today. The topic was legal aspects of charting. He was
   interesting and I learned how important charting is.-----------------------------
   --------------------------------------------------------------------------------M. Smith, HSS )

7. Use the color ink according to your hospital’s policy. Some hospitals require
   black for everything and some require blue for everything. (You may use
   blue or black ink for your Daily Diary entries.)

8. Use military time when charting. This prevents errors on what time of day
   something occurred. Chart all pertinent information about the patient including
   time of vital signs, procedures, and departure/return times when the patient
   leaves the unit. (Use only military times in your Daily Diary.)

9. Use standard medical abbreviations. The medical facility will have a list of
   approved abbreviations. Legally, if you use unapproved abbreviations, an
   attorney can argue that policy was not followed which could lead to errors
   from a misinterpretation of the entry. Use the list of medical abbreviations
   from your textbook as the approved list to use in the Daily Diary.)

10. The proper heading must be present on every sheet of a patient’s chart. In
    may be written, stamped, or printed according to hospital policy. For the
    Daily Diary, write your name and block at the top of each page.)

11. Use the present or past tense. Do not use the future tense. If you document
    your entry after the event then past or present tense will come naturally. (See
    basic rule #3.) In addition, it is not necessary to use the term “patient” with
    every entry. The chart belongs to the patient, therefore, every entry is
    obviously about the “patient”. (Use only present or past tense in your daily
    diary.)

12. Spell correctly. If you are not sure about the spelling of a word, use the
    dictionary to look it up. If you do misspell a word, see basic rule #2 for the
    acceptable way of correcting an error. (Refer to the rubric checklist to see
    the points counted off for misspelled words. Remember, even one
    misspelled word loses you all the points.)

				
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posted:3/9/2012
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