Embed Size (px)
Citation preview
Introduction
The quality of records maintained by nurses is a reflection of the quality of care provided by them to patients/clients.
Intro…
Nurses are professionally and legally accountable for the standard of practice which they deliver and to which they contribute. Good practice in record management is an integral part of quality nursing practice.
The best offense is a good defense. In the world of nursing and Malpractice, the best way to avoid having to defend yourself in court is to chart factually and defensively.
METHODS (STYLES) OF CHARTING
NARRATIVE SOAP
SOAPIER FOCUS
DATA
ACTION
RESPONSE PIE EXCEPTION
CHARTING
NARRATIVE CHRONOLOGICAL BASELINE CHARTED Q SHIFT
LENGTHY, TIME-CONSUMING
SEPARATE PAGES FOR EACH SOURCE-ORIENTED
SOAP USED FOR PROBLEM-ORIENTED CHARTS
S – SUBJECTIVE. WHAT PT TELLS YOU. 0 – OBJECTIVE. WHAT YOU OBSERVE, SEE. A – ASSESSMENT. WHAT YOU THINK IS GOING ON
BASED ON YOUR DATA. P – PLAN. WHAT YOU ARE GOING TO DO.
CAN ADD TO BETTER REFLECT NURSING PROCESS I – INTERVENTION (SPECIFIC INTERVENTIONS
IMPLEMENTED) E – EVALUATION. PT RESPONSE TO
INTERVENTIONS. R – REVISION. CHANGES IN TREATMENT.
EXAMPLE OF SOAP CHARTING
#1 ALTERATION IN COMFORT. ABDOMINAL PAIN.
S – COMPLAINS OF PAIN IN RUQ
O – IS PALE AND HOLDING RIGHT SIDE
A – RECURRING ABDOMINAL PAIN
P – PUT ON NPO AND NOTIFY PHYSICIAN
CHARTING
Describes the patient’s perspective and focuses
on documenting the patient’s current status, progress
towards goals, and response to INTERVENTIONS.
CHARTING
Is a method for organizing health information of
The individuals record.
It is a systematic approach to documentation,
using nursing terminology to describeindividuals status and nursing action.
The importance of charting/ Proper documentation
This involves knowing
How to chartWhat to chartWhen to chartWho should chart
HOW TO CHART
Rule # 1: Stick to the factsRecord only what you1.See2.Hear3.Smell4.Measure andCount not what you1.Infer /Assume (opinions)
HOW TO CHART…..
Ex. If the pt. pulled out his IV line, but you did not witness him doing
Chart subjective data only when it’s supported by documented facts.
HOW TO CHART…..
Rule # 2: Avoid labeling.
Objectively describe the patient’s behavior instead of subjectively labeling it.
HOW TO CHART…..
Rule # 3: Be specific.3.1 Your charting goal is to present the
facts clearly and concisely.3.2 Use only approved abbreviations
and observations in a quantifiable terms.
3.3 Eliminate bias.
HOW TO CHART…..
Rule # 4: keep the record intact.
What to Chart
Rule # 1 – Chart significant Situations
What to Chart…
Rule # 2 – Chart complete Assessment data
When to Chart…
Rule # 1: Document nursing care when you
perform it or shortly afterwards.
Never document ahead of time.
Who should Chart?
Rule # 1: No matter how busy you are, never ask another nurse to complete your charting.
WHAT SHOULD BE DOCUMENTED?
Environmental factors ( safety,equipment ),self care,
Client educationClients outcomes , clients response to treatments, or preventive careDischarge assessment dataMore comprehensive notations to clients whoare seriously illAll relevant assessment data, including monitoring Strips Information related any client transports
WHAT SHOULD BE DOCUMENTED?
Collaboration / communication with other health care providers
Medication administrationVerbal ordersTelephone orders
Focus Charting
PURPOSE of FocusCharting
- Brings the focus of care back to the patient and patient’s concern
- Instead of a problem list, or list of medical and nursing dx, a focus column is used that incorporates many aspects of patient and patient care.
OBJECTIVE
1. To easily identify critical patient issues /
Concerns in the progress notes.
2. To facilitate Communication among all Disciplines.
GENERAL GUIDELINES
1.Focus charting must be evident at least once
every shift.2. 1.Focus charting must be patient-
oriented not nursing task-oriented.3. Document only patient’s concern
and/or plan of care.Ex. Health teaching per shift
GENERAL GUIDELINES ….
4. Document patient’s status on admission, for every transfer to/from another unit or discharge.
5. Follow the do’s of documentation.6. For eight hours shift, use blue or black
ink for morning and afternoon shifts, red ink for night shift.
Specific Guidelines
1. Begin with comprehensive assessment of the patients using inspection, palpation, percussion and auscultation (IPPA).
2. Include in the assessment, collection of information from the patient, family, existing health records (such as checklist/flow sheets, lab results and that of other health care providers.
Specific Guidelines….
3. Establish a focus of care, to be addressed in the Progress notes.
FOCUS
A current individual concern or behavior,
ex. Nausea, Chest pain A sign or symptoms of importance to
the nursing, medical diagnosis, or treatment
plan,
Ex. Fever, Constipation
FOCUS
An acute change in an individuals conditionex.Respiratory distress, seizure
A significant event in an individuals care ex.
Change in diet catheterizationA key word or phrase indicating
compliance with standard care or policy.
Ex. teaching plan
FOCUS…. The focus might be patient strength,
problem, or need. Topics that may appear in the focus Column include patient’s concern and
behaviors;Therapies and responses; changes of
condition; Significant events such as teaching,
consultation, Monitoring, management of activities of daily living or assessment of functional health patterns.
FOCUS CHARTING USES NARRATIVE DOCUMENTATION
(DAR) DATA – SUBJECTIVE OR OBJECTIVE THAT
SUPPORTS THE FOCUS (CONCERN)
ACTION – NURSING INTERVENTION
RESPONSE – PT RESPONSE TO INTERVENTION
FOCUS….
The narrative portion of focus charting includes
Data, Action and Response ( D A R ).
Data ……
- Is the subjective and/or objective information supporting the stated focus or describing the observation at the time of a significant event.
Action….
- Describes the nursing interventions (independent, basic and perspective) past, present, future.
Response….
- Describes the patient outcome/response to interventions or describes how the care plan goals have been attained.
Focus Note
1. Is necessary to describe a patient’s problem/focus/concern from the care plan- when the purpose of the note is to evaluate progress toward the defined patient outcome from the plan of care.
Ex. - self-care- Skin integrity- Activity tolerance
Focus Note
2. To document a finding- when the purpose of the new note is to document a new sign or symptom or a new behavior which is the current focus of care.
3. To document an acute change in patient’s condition- when there has been an event of new patient condition.
Ex. - Respiratory distress- Seizure
Purpose
(a) responsibility for patient care changes from one department to another to document a significant event or unusual episode in a patient care
(b) when a significant
treatment/intervention took place.
Ex.
• Admission • Pre-(specify procedure) assessment • Post-(specify procedure) assessment • Pre-transfer assessment • Discharge planning • Discharge status• Transfusion RBC• Begin thrombolytic therapy• PRN medication required
To document an activity or treatment that was not carried out-when treatment or activity in the flow sheet was not provided to the patient or was different from the standard of care.
To describe all specific patient/family teaching.
This is in compliance with a standard of care.
ex. - Social service/financial assistance
Dietitian/instruct low fat diet Physical therapy/crutch walking
To best describe patient’s condition in relation to medical diagnosis
When the patient’s focus is the pathophysiology rather than patient’s response to the problem.
This happens most frequently in highly technical areas such as critical care.
Data statements contain objective and/or subjective information.
Action statement contains only nursing interventions (basic, perspective,independent) past, present or future.
Patient outcome are evident in the response statements.
Data,Action,Response only contain information related to the focus , none of the information is extraneous (e.g., asleep, watching TV, visited by family)
Response statements are documented after PRN medications are administered.
Information from all those categories (Data, Action, Response) should be used only as they are relevant or available.
However, all appropriate information should be included to ensure complete documentation.
DATA and ACTION are responded at one hour and RESPONSE is not added until later, when the patient outcome is evident.
Response is used alone to indicate that a care plan goal has been accomplished.
DATE/TIME
FOCUS
DATA, ACTION, RESPONSE
03/08/08 7-3pm10 am
12 noon
1:05 pm
Chest pain
D:” Sumasakit ang dibdib ko,” Midclavicular line pain of 4 on scale of 5
A; Medicated with Isordil 5mg. SL. Peterson Angsingco, RN
R: resting in bed.” Nabawasan na ng sakit ang dibdib ko.” Pain scale Rating of 2 Peterson Angsingco , RN And so on……………
DATE / TIME09/15/087-3 pm
10 AM
FOCUS
HealthTeaching:DressingChange
DATA, ACTION, RESPONSE
R: Patient demonstrated, he is able to change his
own abdominal dressing using
aseptic technique.
Bea Alonzo, RN
Ex.
DATE / TIME 19/15/087-3 pm10 AM
FOCUS
Post Transfer Assessment
DATE, ACTION, RESPONSED: Received from RR via stretcher, awake and alert, vital signs stable. IV right forearm patent, Foley in place with clear yellow urine, dressing in RLQ is clean and dry ;moving all extremities voluntarily,” Minimal incisional pain at this time rating 3. Bea Alonzo RN.
ACTION AND RESPONSEex.
DATE / TIME09/15/087-3pm9 AM
FOCUS
Nausea
DATA, ACTION, RESPONSE
D:” I feel like my stomach is filling up with pressure again
and I'm nauseated”,
Abdomen round and
soft, Gastrostomy bag at body
level, (rate of bowel sounds.)
Cont……
9:15 am
9:30 am
A: Gastrostomy bag lowered
R: “ I feel better now.” Approximately 200 cc gastric fluid; returned as much flatus
A: Keep gastrostomy bag below body level.Bea Alonzo, RN
Begin the note with ACTION when the patient’s interaction begins with intervention or when including data would be unnecessary repetition.DATE / TIME09/15/08
9 AM
FOCUSHealth
TeachingDigoxin
DATA, ACTION, RESPONSEA: Patient
instructed on the actions and side
effects of digoxin. Given digoxin
information card, discussed when he
would call the physician
About the medicine.R: Return
demonstration of radial pulse.” I understand the
purpose of medication”,
Bea Alonzo, RN
DATE / TIMEO9/15/08
9 AM
9:10 am
9:20 AM
FOCUS
Pain at IV site
DATA, ACTION, RESPONSE
D -” masakit and pinaglagyan ng
dextrose ko”, Check IV site, found
beginning signs of infiltration.
A –” Remove IV, change the whole system, reinserted
the new set aseptically into the
distal portion of basilic vein, left arm anchored , splint applied,
advised to call nurse for any presence of
pain.R –” Wala na ang
sakit ng pinaglagyan ng dextrose ko”.
SUMMARY
Focus charting can help you monitor patient problems and avoid repetitious documentation, a focus which may be written as a nursing diagnosis can be changed as an acute condition, a potential problem, a treatment procedure or a patient behavior.
Again …..
The quality of records maintained by nurses is a reflection of the quality of care provided by them to patients/clients.
Case 1
A patient is 8 hours post op and complaining of moderate pain at the abdominal incision site. The blood pressure is slightly elevated, 130/80. The pain medication ordered is not due for another hour.
Case 2
. A patient has COPD. He constantly complaints of coughing, fatigue and sputum production. During the assessment, the nurse observes his breathing pattern. She notes the barrel-chest that is common in COPD patients.
Case 3
A patient is transferred to the medical-surgical ward for congestive heart failure. Shortly after admission, the nurse assesses his condition. He is dyspneic and slightly cyanotic.
Case 4
Post-operatively a patient voids 50 ml of clear yellow urine three times, but continuous to complain that the bladder does not feel empty.
Thank you and God bless !!!
Elvira Cachuela- Atuel, RN, MAN, US-RN
Workshop
Group 1A 17 year old boy is admitted to the
male ward from ER with difficulty of breathing; HR of 102 bpm; temp. 36.5; RR 16; with tentative diagnosis of Chronic bronchitis
Group 2
An 8 month old baby with AGE; poor sucking; sunken eyes and poor skin turgor; still with bouts of diarrhea 3 times within 1 hour in the ward.
Group 3
A 75 year old male is was admitted with complaint of SOB, now complains of chest pain two days after admission; has previous history of MI; pain scale is 6 of 10
