| A | B |
|---|
| DOCUMENTATION | PROVIDES A WRITTEN RECORD OF THE HISTORY, TREATMENT, CARE AND RESPONSE OF THE PATIENT WHILE UNDER THE CARE OF A HEALTH CARE PROVIDER |
| EACH PERSON WHO PROVIDES CARE | ADDS WRITTEN DOCUMENTATION TO THE MEDICAL RECORD OR CHART |
| DOCUMENTATION, ALSO CALLED CHARTING | TRACK THE APPLICATION OF THE NURSING PROCESS |
| THE WRITTEN NURSING PLAN PROVIDES | THE FRAMEWORK FOR CONTINUITY OF CARE |
| THE MEDICAL RECORD OR CHART | CONTAINS DATA ON A PATIENT'S STAY IN THE HEALTH FACILITY OR WHILE UNDER THE CARE OF A HEALTH PROVIDER |
| THE MEDICAL RECORD | IS A LEGAL RECORD, IT'S CONTENTS MUST BE KEPT CONFIDENTIAL |
| CONFIDENTIAL | PRIVATE |
| ONLY THOSE HEALTH PROFESSIONALS CARING DIRECTLY FOR THE PATIENT | SHOULD HAVE ACCESS TO THE CHART |
| (GENERAL FORMS) PHYSICIAN'S ORDERS INCLUDES: | THE PHYSICIAN'S DIRECTIVES FOR PATIENT CARE |
| (GENERAL FORMS) GRAPHIC SHEET | RECORD OF SERIAL MEASUREMENTS AND OBSERVATIONS, EX: TEMP, PULSE, RESPIRATION, NURSING INTERVENTION |
| (GENERAL FORMS) NURSING CARE PLAN | PLAN OF CARE FOR THE PATIENT INCLUDING NURSING DGX'S, GOALS/EXPECTED OUTCOMES AND NURSING INTERVENTIONS |
| (GENERAL FORMS) NURSE'S NOTES | WRITTEN REPORT OF THE NURSING PROCESS (ASSESSMENT, NURSING DGX, PLANNING, IMPLEMENTATION, EVALUATION) RECORD OF INTERVENTIONS IMPLEMENTED AND THE PATIENTS REPSPONSE TO THEM |
| (GENERAL FORMS) ACTIVITY FLOW SHEET | FORM ON WHICH CHECKMARKS OR SHORT ENTRIES ARE MADE TO INDICATE DIETARY INTAKE, TYPE OF BATH, WOUND DRESSING CHANGES, OXYGEN IN USE, DR VISITS, EQUIPMENT IN USE, ACTIVITY LEVEL... |
| (GENERAL FORMS) MEDICATION ADMINISTRATION RECORD (MAR) | DOCUMENTATION OF ALL MEDS ORDERED, DOSES GIVEN, DOSES NOT TAKEN BY THE PATIENT |
| (GENERAL FORMS) HISTORY & PHYSICAL EXAMINATION FORMS | DR'S RECORD OF THE PATIENT'S MEDICAL HX, FINDINGS OF THE CURRENT PHYSICAL EXAM |
| (GENERAL FORMS) NURSE'S ADMISSON HISTORY AND ASSESSMENT | NURSE'S CURRENT HX, HABITS, MEDS USUALLY TAKEN, PHYSICAL ASSESSMENT FINDINGS AT ADMISSION |
| (GENERAL FORMS) PROGESS SHEET | PHYSICIAN'S NOTES REGARDING THE PATIENT'S PROGRESS |
| (GENERAL FORMS) LABORATORY REPORTS | RESULTS OF LAB TESTS |
| (GENERAL FORMS) RADIOLOGY REPORTS | RESULTS OF X-RAY EXAMINATIONS |
| (GENERAL FORMS) INTAKE & OUTPUT RECORD | SERIAL RECORD OF 24-HOUR INTAKE AND OUTPUT |
| (SPECIAL FORMS) DISCHARGE PLANNING SHEET | RECORDS BY SOCIAL SERVICES HOME HEALTH AGENCIES, AND CLINICAL NURSE SPECIALISTS REGARDING THE DISCHARGE PLANS AND NEEDS OF THE PATIENT |
| (SPECIAL FORMS) CONSULTATION SHEET | RECORD OF ANOTHER PHYSICIAN CALLED IN TO CONSULT BY THE ATTENDING DR |
| (SPECIAL FORMS) SURGICAL OR TREATMENT CONSENT FORM) | PATIENT AUTHORIZATION FOR SURGERY OR TREATMENT |
| (MISC FORMS) DIABETIC FLOWSHEET | RECORD OF BLOOD SUGAR DETERMINATIONS AND AMOUNTS OF INSULIN ADMINISTERED |
| (MISC FORMS) PREOPERATIVE CHECK LIST | LIST USED TO VERIFY THAT THE PATIENT IS READY TO GO TO SURGERY |
| FREQUENT OBSERVATIONS SHEET | USED WHEN VERY FREQUENT MEASUREMENTS OF VITAL SIGNS OR NEUROLOGIC ASSESSMENT ARE NEEDED (AFTER SURGERY, OR AFTER HEAD TRAUMA) |
| (MISC FORMS) INTRAVENOUS FLOWSHEET | RECORD OF IV FLUIDS, AND ADDITIVES INFUSED, TYPE OF IV CATHETER IN USE, DATE TUBING WAS CHANGED, DATE DRESSING WAS APPLIED |
| (MISC FORM) DISCHARGE FORM | INFO ABOUT INSTURCTIONS GIVEN REGARDING WOUND CARE, MEDS, REST, ACTIVITY RESTRICTIONS, NEEDED EXERCISES, DIET AND S/S TO REPORT TO THE DR, ALSO INCLUDES WHEN TO NEXT SEE THE DR |
| AFTER THE PATIENT HAS BEEN DISCHARGED | THE CHART IS SENT TO THE MEDICAL RECORDS OR HEALTH INFO DEPT FOR SAFEKEEPING, IT CAN BE RETRIEVED IF THE PATIENT IS ADMITTED TO SERVICE AGAIN WITHIN A 10 YEAR SPAN |
| (METHODS OF CHARTING) SOURCE-ORIENTED | CHART ARRANGED BY DEPARTMENT, DOCTOR, NURSING |
| (METHODS OF CHARTING) PROBLEM-ORIENTED MEDICAL RECORD (POMR) | FOCUSES ON THE PROBLEMS EXPERIENCED BY THE PATIENT AS A RESULT OF BEING ILL OR ON THE DEFINED NURSING DGX REFLECTING THOSE PROBLEMS |
| (METHODS OF CHARTING) CHARTING BY EXCEPTION | FOCUSES ON DEVIATIONS FROM PREDEFINED NORMS, USING PRESET PROTOCOLS AND STANDARDS OF CARE |
| (METHODS OF CHARTING) COMPUTER-ASSISTED CHARTING | WHERE DATA ARE INPUT TO THE COMPUTER |
| SOURCE ORIENTED OR NARRATIVE CHARTING DISADVANTAGES | IT ENCOURAGES DOCUMENTATION OF BOTH NORMAL AND ABNORMAL FINDINGS, MAKING IT DIFFICULT TO SEPARATE PERTINENT FROM IRRELEVANT INFO, IT REQUIRES EXTENSIVE CHARTING TIME BY THE STAFF, IT DISCOURAGES DR'S AND OTHER HEALTH MEMBERS FROM READING ALL PARTS OF THE CHART BECAUSE OF LONG DESCRIPTIVE ENTRIES |
| PROBLEM ORIENTED MEDICAL RECORD (POMR) | ALL CARE GIVERS CHART ON THE PROBLEMS SHEETS. PROVIDES CONTINUITY OF CARE |
| PROBLEM ORIENTED MEDICAL RECORD DOCUMENTATION (POMR) | FOCUSES ON THE PATIENT STATUS RATHER THAN ON MEDICAL OR NURSING CARE, ITS PROBLEM SOLVING APPROACH TO PATIENT CARE AND PROVIDES A METHOD FOR COMMUNICATING WHAT, WHEN, AND HOW THINGS ARE TO BE DONE IN ORDER TO MEET THE NEEDS OF THE PATIENT |
| S IN SOAP CHARTING STAND FOR | SUBJECTIVE INFORMATION (SYMPTOMS) |
| O IN SOAP CHARTING STANDS FOR | OBJECTIVE INFORMATION (SIGNS/FACTS) |
| A IN SOAP CHARTING STANDS FOR | ASSESSMENT DATA |
| P IN SOAP CHARTING STANDS FOR | IS THE PLAN |
| UNDER THE P OF THE PIE CHART | THE PROBLEMS,TEACHING AND DISCHARGE NEEDS ARE LISTED, NURSING DGX ARE KEPT ON A PROBLEM LIST, AND EACH CHARTING ENTRY IS MARKED WITH THE PROBLEM NUMER AND TITLE, WITH THIS METHOD THE DAILY ASSESSMENT INFO IS PLACED ON FLOWSHEETS AND DUPLICATION OF THE INFO IS AVOIDED |
| UNDER THE I OF THE PIE CHART | INTERVENTIONS PERFOMED ARE DOCUMENTED HERE |
| UNDER THE E OF THE PIE CHART | THE OUTCOMES OF THE INTERVENTIONS ARE EVALUATED AND DOCUMENTED HERE |
| CHARTING BY EXCEPTION | IS BASED ON THE ASSUMPTION THAT ALL STANDARDS OF PRACTICE ARE CARRIED OUT AND MET WITH A MORMAL OR EXPECTED RESPONSE UNLESS OTHERWISE DOCUMENTED |
| CHARTING BY EXCEPTION IS | THE DIRECT OPPOSITE OF THE SAYING" IF IT WASNT CHARTED, IT WASNT DONE", IT ASSUMES THAT UNLESS DOCUMENTATION TO THE CONTRARY, ALL STANDARDS AND PROTOCOLS WERE FOLLOWED AND ALL ASSESSMENT VALUES WERE WITHIN ACCEPTED LIMITS |
| CHARTING BY EXCEPTION METHOD | MAY PRESENT SOME PROBLEMS WITH LEGALITIES WHEN A CHART IS CALLED INTO COURT BECAUSE ONLY ABNORMALITIES ARE DOCUMENTED IN WRITTEN WORDS |
| ADVANTAGES OF CHARTING BY EXCEPTION | HIGHLIGHTS ABNORMAL DATA/PATIENT TRENDS, DECREASES NARRATIVE CHARTING TIME, ELIMINATES DUPLICATE CHARTING |
| DISADVANTAGES OF CHARTING BY EXCEPTION | REQUIRES DEVELOPMENT OF DETAILED PROTOCOLS/STANDARDS, REQUIRES RETRAINING STAFF TO USE UNFAMILIAR METHODS OF RECORD KEEPING/RECORDING, NURSES BECOME SO USED TO NOT CHARTING THAT IMPORTANT DATA IS SOMETIMES OMITTED |
| ADVANTAGES OF COMPUTER ASSISTED CHARTING | DATE/TIME AUTOMATICALLY RECORDED, NOTES ARE LEGIBLE, QUICK COMMUNICATION BETWEEN DEPTS, INFO MORE ACCURATE, COST EFFECTIVE, ELECTRONIC RECORDS ARE ACHIEVED QUICKLY, HOSPITAL GETS PAID FASTER |
| DISADVANTAGES OF COMPUTER ASSISTED CHARTING | SECURITY/CONFIDENTIALITY, INITAL COSTS PRICY, TRAINING STAFF COSTLY, COMPUTER DOWN TIME CAN CREATE PROBLEMS OF IMPUT, ACCESS, TRANSFER OF INFO |
| THE KARDEX | WORK TOOL, NEEDS TO BE KEPT UP TO DATE, QUICK REFERENCE FOR CURRENT INFO ABOUT PAIIENT AND ORDERED TREATMENTS, UNIT SECRETARY HAS IT AND UPDATES IT WITH THE PRIMARY NURSE |
| THE KARDEX INCLUDES | ROOM#, NAME, AGE, SEX, ADMITTING DGX, DR'S NAME, SURGERY DATE, DIET, TESTS/PROCEDURES, ACTIVITY LEVEL, NURSING ORDERS FOR ASSISTIVE/COMFORT/, MEDS, IVS |
| GUIDELINES FOR CHARTING ABOUT A SIGN OR SYMPTOM | LOCATION IN THE BODY-DESCRIBE THE EXACT LOCATION |
| GENERAL GUIDELINES FOR CHARTING | BEFORE BEGINNING TO CHART, VERIFY NAME ON CHART AND THE PAGE, EACH PAGE SHOULD HAVE IMPRINT OF NAME AND HOSPITAL NUMBER ON IT, USE BLACK INK, DATE/TIME OF EACH ENTRY IN MILITARY TIME, CHART THE INITIAL ASSESSMENT, CHARTING IS DONE ONLY BY THE PERSON WHO MADE OBSERVATION/PROCEDURE AND WHO IS LEGALLY RESPONSIBLE, AFTER NOTE IS COMPLETE SIGN WITH ONE INITAL PLUS LAST NAME AND TITLE, P. KIRKWOOD, SPN, CHART OBJECTIVE DATA AFTER EACH TASK/ NOTHING IS CHARTED BEFORE IT IS ACTUALLY DONE, NO BLANK LINES ARE LEFT IN CHARTING, A LATE ENTRY MAY BE MADE IF SOMETHING HAS BEEN FORGOTTEN, WRITE TIME OF ENTRY/CIRCLE IT AND WRITE LATE ENTRY AND YOUR INITALS ABOVE THE TIME, CLARIFY ID CARE GIVEN BY ANOTHER HEALTH PERSON, |
| WHEN A PERSON REFUSES MEDICINE | A CIRCLE IS PLACED ON THE MAR RECORD AROUND THE TIME THE MED WAS TO BE GIVEN, AN EXPLAIN REFUSAL IN PROGRESS NOTES. REFUSAL OF TREATMENTS ARE HERE ALSO, ALSO EXACT WORDS PATIENT USED WHILE REFUSING |
| SPELL CHART ENTRIES CORRECTLY | USE DICTIONARY IF NEEDED |
| IF YOU MAKE ERROR ON CHART, DRAW A LINE THROUGH THE INCORRECT WORD OR PHRASE AND WRITE THE WORD ERROR ABOVE IT | ADD THE DATE/MY INITIALS, SOME WRITE MISTAKEN ENTRY OR INCORRECT ENTRY RATHER THAN ERROR |
| THE PRIMARY PURPOSE OF CHARTING THE CARE OF A HOSPITALIZED PERSON IS TO PROVIDE | A WRITTEN HISTORY OR RECORD |
| IN CHARTING BY EXCEPTION | PREDEFINED ASSESSMENT PARAMETERS, PROTOCOLS, AND STANDARDS ARE REQUIRED |
| A DISADVANTAGE OF COMPUTER ASSISSED CHARTING IS | ABSOLUTE SECURITY/CONFIDENTIALITY OF PATIENT RECORDS MAY BE DIFFICULT TO MAINTAIN |
| WHEN CHARTING THE PATIENTS CONDITION AND NURSING CARE, THE NURSE RECORDS | PATIENT STATMENTS AND BEHAVIORS THAT ARE OBSERVED OR MEASUREMENTS |
