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					       Documentation


NUR101
Lecture #5
Fall 2008
K. Burger, MSED, MSN, RN, CNE
PPP by S. Niggemeier, MSN, BSN, RN
   Purpose of Documentation
 Supports Nsg          Education
  actions indicates     Quality
  client’s condition
                         Assurance
 Primary
  communication         Research
  tool                  Historic and
 Legal protection       legal document
 Reimbursement         Decision analysis
    Types of Documentation
 Nurses Notes
 Flow sheets
 Graphics
 Nursing Care Plans
 Caremaps
 Critical Pathways
 Computer charting
Methods of Documentation
 Traditional (source
  oriented client record)
 Problem Oriented Medical
  Record (POMR)
  -SOAP
  -PIE
  -Focus DAR
 Charting by exception
       Documentation
 NN (nurses notes) best assessment
  of pt. care.
  Most used section of the medical record in legal cases
 Documentation or Charting is a skill
 Record of pt.’s condition, activities
  and events that occurred to the
  PATIENT.
 Not a diary of your activities.
 Includes Subjective & Objective
  info
Documentation
 Chart facts, not your opinion
 Use quotations if pt. said it.
 Be specific!! Using nonspecific terms
  implies doubt about your knowledge.
  i.e. appears/seems/tolerated well etc.
 In most cases when care or
  observations are not charted it means it
  wasn’t done
 ABC’s: Accuracy/Brevity/Completeness
Guidelines for Documentation:
         Content
 Focus on pt.
 Not a novel or essay
 Use short sentences
 Abbreviations
 Symbols
 Don’t need to use word pt.
 Guidelines for Documentation:
             Timing
 Chart as soon as possible after
  care/observations
 NEVER chart what you plan to do
 Date & time each entry in the margin
Guidelines for Documentation:
            Format
  Use forms as per agency policy(i.e. flow
   sheets, graphic sheet, NCP, progress
   notes)
  Follow agency guidelines regarding color
   ink, approved abbreviations, format of
   time (i.e. military/standard)
  Write LEGIBLY-questionable info implies
   doubt suggests you lack reasonable
   knowledge
  NEVER skip lines!!
  Use correct grammar/spelling
Guidelines for Documentation:
        Accountability
    Record is permanent
    Sign full name and title
    No erasures
    Do Not write ERROR for a mistake
    Single line thru mistake, print
     “Mistaken Entry” or ME (if
     acceptable) above or next to
     mistake, enter correction, initial &
     date per policy
 Guidelines for Documentation:
         Confidentiality
 Students only use patient initials on
  assignments
 Only caregivers need to know info in
  chart
 Follow facility policy for pt. review of
  chart.
Other Guidelines for
Documentation
 Hospitals-
  computers

 Home care-
  laptops

 Telephone
  orders

				
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posted:8/19/2011
language:English
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