IDENTIFY THE FF. ABBREVIATIONS:

1. DAT2. o.u.3. b.i.d4. BP5. gtt.6. h.s.7. IM8. IV9. p.o10. KVO

11. p.c.12. p.r.n.13. a.c.14. q.i.d.15. k.s.s16. Stat17. T.i.d.18. q. 15 mins.19. NGT20. KUB

The quality of records maintained by nurses is a reflection of the quality of the care provided by them to patients / clients.

Documentation

Written evidence of the interactions between and among health professionals, clients, their families and health care organizations.

Written evidence pt. of the administration of test,Procedures treatment and client education.

The results of clients response to the diagnostic test and interventions.

Purposes of documentation

professional responsibilityaccountability

communication

educationresearch

Meeting legal and practical standards

reimbursements

The best offense is a good defense.

This involves knowing How to chart

What to chart

When to chart

Who should chart

HOW TO CHART Rule # I Stick to the facts- Record only what you see, hear,

smell, measure and count not what you assume.

- Don’t chart your opinions.

- Chart subjective information only when its supported by documented facts.

Rule # 2. Avoid LabelingObjectively describe the

patients behavior instead subjectively labeling it.

Rule # 3- Be specific Your charting goal is to present the

facts clearly and concisely.

Use only approved abbreviations and observations in a quantifiable terms.

Eliminate bias. Don’t use language that suggests a negative attitude toward the patient. If the patient is difficult or uncooperative, document the behavior objectively and let the lawyers draw their own conclusions.

Rule # 4 – Keep the record intact.Discarding pages , even for

innocent reasons, raises doubt in a lawyers mind.

What to ChartRule # I – Chart significant situationsLearn to recognize legally

dangerous situations as you give patient care. Assess each critical or out of the ordinary situations and decide whether your actions might be significant in court.

Rule # 2 – Chart complete assessment data The failure to perform and document a

complete physical assessment is a key factor in many malpractice suits.

During your initial assessment , focus on the patient chief complaint, then follow up on all other problems he mentioned. Be sure to chart everything you do and why.

When to Chart.Rule #1 - Document nursing care when you

perform it or shortly afterwards.

Never document ahead of time.

Who should ChartRule # I – No matter how busy you are,

never ask another nurse to complete your charting

HOW SHOULD INFORMATION BE DOCUMENTED

CLEARLY, COMPREHENSIVELY,

COMPLETELY

ACCURATELY HONESTLY

HOW SHOULD INFORMATION BE DOCUMENTED?

Date and Time

Legibility

Spelling

permanence

Changes or additions

Abbreviations

WHEN SHOULD INFORMATION BE DOCUMENTED

TIMELY

FREQUENTLY

CHRONOLOGICALLY

Admission Nursing AssessmentNursing Care PlansKardexesFlow SheetsProgress NotesNursing Discharge/Referral Summaries

Initial data base, nursing history or

nursing assessment

Can be organized according to health

patterns, body systems, functional

abilities, health problems and risks,

nursing model or type of health care

setting

Admission Nursing Assessment

Clinical record include evidence of client assessments, nursing diagnoses and /or client needs, nursing interventions, client outcomes and evidence of nursing care plan

Concise method of organizing and recording data about a client

Series of cards kept in a portable index file or computer generated forms

Pertinent info about the client..name, rm 3, age, admission date etc

Allergies List of medications List of iv’s List of treatments and procedures Diagnostic procedures

Pt.’s data: Traya, Jun Rey 17 y.o dr. ferrer, stab wound

Pls admit under GS1 Vs q 4hrs and record Measure I and O and record Start IVF of D5LR 1L to run at 120cc/hrLabs: cbc, BT

> U/a> Se crea, Na, K> CXR PA > USD of abdomen

Meds:> cefuroxime 750 mg q8 IVTT>Ranitidine 50mg q8 IVTT> TT 0.5 mg left deltoid IM> HTIG 250 iu right deltoid IM> Tramadol drip (300mg +D5W 500 cc) to run in 24hrs> Ketorolac 30 mg q 8

MHBR, O2 inhalation at 4lpm, daily oral carerefer

used as a quick way to reflect or show clients condition

Graphic Record Indicates body temperature,pr,rr,bp.wt

Intake and Output Record Medication Administration Method

the time parameters for a flow sheet can range from minutes to months.

Provide information about the progress a client is making toward achieving desired outcomes

Include information about client problems and nursing intervention

Completed when the client is being discharged and transferred to another institution or to a home setting

Includes instructions for care and the final progress

• In a mal practice suit, good documentation in the medical records can be ones best friend or worst enemy.

• If a claim is not settled and proceeds to trial, the most important evidence presented to the COURT is the medical record.

• The COURT uses the medical record as a legal guide to assess the health care providers professional conduct to determine whether they adhered to or deviated from the standard

• As a preventive liability tool. If a nurse does not document the care provided, treatments may jeopardize the patient safety.•

In conclusion, the nurse documentation is a legal record that provides information about the continuity of care from admission to discharge.

Careful documentation is one of the best defenses against liability exposure and provides a supportive record of medical and treatment interventions and evidence of quality patient care.

Remember that what you write today, can save you and your license in the future, should the record end up in a court room.

“ IF YOU DIDN`T CHART IT, IT WASN`T DONE”.