Documentation by liwenting


What you need to know!

 Kindred Hospital Louisville
  Shannon Ash, RN, BSN
Sometimes documentation is funny...
    Or just doesn’t quite come out right!

 “Patient has chest pains if she lies on her left side for
    over a year.”
   “By the time she was admitted to the hospital her
    rapid heart had stopped and she felt much better.”
   “On the second day the knee was much better, and
    by the third it had completely disappeared.”
   “While in the emergency department she was
    examined, x-rated and sent home. “
   “Healthy appearing, decrepit 69-year old female,
    mentally alert but forgetful.”

      While the humor can
       certainly be seen in
       some charting
       „mistakes‟, every
       mistaken entry has
       the potential to
       cause problems for
       patients & for staff.
    Purpose of the medical record
   The medical record should be a complete and
    accurate record of the patient's condition and
    treatment. It should allow for clear
    communication between members of the
    healthcare team.
   It is the basis for evaluating health care
    operations and how resources are utilized by
    providing research data and determining
    reimbursement by third party payers.
   It also serves to pursue or defend from
    medical malpractice claims.
    Importance of Medical Record
   The reasons for maintaining a medical
    record clearly illustrate the extreme
    importance of maintaining an accurate,
    thorough medical record.
   Inaccuracies and omissions can lead to
    poor communication, bad continuity of
    patient care, potential lack of
    reimbursement for care, and can open
    up the hospital & caregivers to liabilities.

   The word liability means “the quality or
    state of being obligated according to law
    or equity”.
   It means being responsible for
    something, in this case, being
    responsible for the care delivered to a
    patient of our hospital.

   Who has liability?
    – the Hospital
    – Physicians
    – Hospital Administration
    – Direct providers of care
    – Indirect providers of care
     Golden Rule of Charting #1

   Chart in “real time”.
   Chart things as they happen. This
    makes your findings more likely to be
    charted accurately, decreases
    confusion about what happened when,
    and makes your documentation more
      Golden Rule of Charting #2

   Only chart what you know!
   If you enter a room and find a patient on
    the floor, don‟t chart “patient fell out of
    bed onto floor”. You don‟t know that‟s
    what happened!!
   Instead, document “Patient found sitting
    in floor. Patient states “I tried to get out
    of bed and slipped.””
           What happened here?

   Did the person who charted this witness the event,
 assume that what is described is what happened, or did
      the patient report that it happened this way?
This type can make the information unclear. If this was
witnessed, it is better to say “Witnessed patient sliding to
 end of chair and chair flipping over on top of patient.
Tried to prevent patient from sliding out, but was unable
                  to reach patient in time.”
                 Much clearer

This charting tells us much more clearly what happened.
It’s obvious the caregiver didn’t see the patient pull the
tube out, but documented subjectively what happened.
Don’t forget that any situation like the two described on
these pages also warrants an event report to be filled out
     Golden Rule of Charting #3

   Chart only things YOU do.
   Don‟t chart things that are done by other
    staff members. For example, if a CNA
    obtains vital signs on a patient, the
    nurse shouldn‟t chart them. Your
    charting something means YOU did it.
                Not your work!

The above note describes Hydromorphone being given IV
x 2, not something within the scope of practice by an LPN.
This charting could leave it open to interpretation that this
person gave the meds. If it was given by someone else,
THEY should chart it.
     Golden Rule of Charting #4
   Use subjective terminology.
   Instead of saying “I talked to the family
    member on the phone…” you should
    document “Spoke with daughter on the
   There‟s no need to chart “this therapist
    or this nurse” did something. If you are
    charting it, the presumption is that you
    did it!
Not as good

     Golden Rule of Charting #5

   Proofread your charting!
   You can provide the absolute best care
    in the world to your patients, but if your
    charting has typo‟s, misspellings and
    mistakes, it can appear that you aren‟t
    careful or that you‟re prone to mistakes.
   That‟s not an image you want to project.
          Documentation Tips
   Document professionally.
   If you must refer to other people, refer
    to them by their full names and titles.
   Spell words correctly.
   Don‟t use slang or unapproved
   Don‟t gossip or speculate in the
    patient‟s chart.
   Use punctuation!
Things that should not be charted

This sounds bad to everyone who reads it. Chart what
you did (i.e., gave the medication, and rescheduled the lab
Make an event report if a medication error is made - and
not giving a medication at the appropriate time IS a
medication error.
Things that should not be charted

 This note would have been fine if it weren’t for the line
 with the extreme use of exclamation points. The tone
 of the note is blatantly critical.
  Report factually what happened. Not emotionally.
                  Too casual

Talking about Michelle and Buffy is fine if you guys are
hanging out. Documenting “Michelle” and “Buffy” is
not appropriate in a patient’s chart.
         Make Sure You Chart

   Change of conditions
   Resuscitation records (in computer too!)
   IV Bag & tubing changes
               Don’t Chart
   Administrative problems like “short of
    staff” etc.
   Equipment problems (“glucometer
    display hard to read”)
   Judgemental words “has an abrasive
    voice” “obnoxious and manipulative”
   Meaningless expressions like “pt had a
    good night” use specific examples.
    Important Documentation Tips
   Don‟t chart the same         Don‟t criticize or
    thing on every                make judgements
    patient every day!            about care other
   If the patient is             care that is done.
    resting in bed quietly,      If your professional
    great, but that               opinion is that the
    shouldn‟t be the              care ordered isn‟t
    ONLY thing you                the most appropriate
    chart.                        - inform a supervisor
   Never use slang or            immediately.
    Important Documentation Tips

   Don‟t “double chart”. If you‟re reporting
    changed / altered / new vital signs, don‟t
    make a progress note on it - put it under the
    vital signs section!
   Don‟t ramble! Rambling charting makes you
    sound disorganized or not under control.
   Re-read your progress note after you‟ve
    written it. Have someone else read it if you‟re
    not sure.
             Happy Charting!

   Charting should be like every other
    aspect of your care:
    – Thoughtful
    – Careful
    – Detailed
    – Informative
    – Accurate

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