COMMON ERRORS IN NURSING DOCUMENTATION AND PATIENT RECORD SYSTEM

11/12/2012

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Objectives
At the end of this presentation Candidates will be able to :
Discuss sequence of paper placement in patient record Explore the correct filling of each paper used in patient record Discuss common errors found in nursing documentation and patient record system Demonstrate for maintaining patient files and sequence of paper Exercise for filling nursing related paper found in patient files.
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Sequence of Papers
Investigation Reports Consultation Papers

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01 TPR flow sheets 02 B.P Charting 03 Medication Sheet 04 History Sheet 05 Physical Examination 06 Doctors Orders 07 Progress Notes 08 Nursing Record 09 I/O charting
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Improper sequence

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Investigation Reports
Arranged in time line sequence Must be read by Nurses Know the normal Value Highlight abnormal values only Blood sugar report attached in investigation sequence Write only abnormal values in nursing record Example: patient MP report received at 1:00 pm

MP +Ve, (Falciparum), DR. ABC is informed RN Nomi WG

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Consultation Papers
Time line sequence Must be read by Nurses Record special order in nursing record sheet Example: Patient

was examine by the Eye specialist Dr. ABC, at 11:30 a.m advice for cataract operation tomorrow
RN Nomi WG
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TPR flow sheets

Arranged in time line sequence Must be check by Head Nurse if marked by Student N. Know normal and abnormal Value Highlight abnormal values only Write only abnormal values in nursing record Example: patient temperature at 10:00 a.m was 103 F, Dr. ABC informed , advice Tab. Brufen 400 mg B.D RN Nomi WG (Same for B.P,PULSE & Respiration)
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TPR flow sheets

(Used with BLUE PEN) 01 Name: ..(Mr. ABC) 02 Hospital Number : (1234) 03 Ward/ Room: ..(MW1/01) 04 Day of Month: (01-01-2012.) 05 Day of hospital: .(01,02,03,.) 06 Day of Post operation: ..(1,2,3,4.)
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Empty field

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Mr. ABC

123

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01-01-2011 02-01 01 02 01
02

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Class Activity
Please take out your TPR chart and fill as given below (Used with BLUE PEN) 01 Name: ..(Mr. ABC) 02 Hospital Number : (1234) 03 Ward/ Room: ..(MW1/01) 04 Day of Month: (01-01-2012.) 05 Day of hospital: .(01,02,03,.) 06 Day of Post operation: ..(1,2,3,4.)
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Question

What is A.M & P.M..?

What is Meridian ?
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TPR flow sheets A.m.-----------(Anti Meridian) P.m.------------(Post Meridian) Meridian mean Mid Day (12 MD)

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Question
How to convert Fahrenheit to centigrade? C=(F-32) / 1.8 Convert 98 degree Fahrenheit to centigrade.
36.66 C
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TPR flow sheets (Temperature Charting)

Marking in Degree Fahrenheit (95 F to 107 F) Highlight Normal value (98.6) with redline

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Fahrenheit (95 F to 107 F)

(98.6) with redline

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Class Activity
Please take out you TPR chart Circle Normal Value and draw a line with Red ball point
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TPR flow sheets (Temperature Charting)

Used BLUE Ball Point for marking Comments for special marking
Example: On admission After medication After blood tranfusion
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Class Activity
Please take out your TPR chart Fill the following values 01-01-2012 ------- 5 a.m 101 F (adm..) 01-01-2012 ------- 1 p.m 98 F 01-01-2012 ------- 9 p.m 104 F 02-01-2012 ------- 5 a.m 101 F 02-01-2012 ------- 1 p.m 98 F 02-01-2012 ------- 9 p.m 104 F (aft. Blood trf)
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On Admission

Result

After blood transfusion (104 F)

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Abnormal reading must be noted in nursing note: Example: Patient temperature at 9 P.M is 104 F (post blood transfusion) , DR. ABC is informed advice to shift the patient in critical area immediately RN Nomi WG
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TPR flow sheets (Temperature Charting)

DO NOT DO this .? Multicolor marking only used Blue Ball pen Bold marking for LINE (______)and DOT (.) Comma like marking (,) Dirty marking Pencil Marking
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BOLD type Dots..

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Out of line

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Mountain like marking

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Dirty marking with no time sequence

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Comma like marking

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NON Medical terms???

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Dirty/ Wrong marking

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Multiple Dirty/ Wrong marking

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Correct Marking

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TPR flow sheets (PULSE Charting)

Marking in numeric / min. (10 to 160) Highlight Normal line with redline Used RED Ball Point for marking Comments for special marking
Example: On admission After medication After blood transfusion e.t.c
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TPR flow sheets (PULSE Charting)

DO NOT DO this .? Multicolor marking only used RED Ball pen Bold marking for LINE (______)and DOT (.) Comma like marking (,) Dirty marking Wrong Marking Pencil Marking
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Multi color marking

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Multi color marking

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Class Activity
Please take out your TPR chart Fill the with the following marking of PULSE/MIN 01-01-2012 ------- 5 a.m 120 (Adm..) 01-01-2012 ------- 1 p.m 80 01-01-2012 ------- 9 p.m 140 02-01-2012 ------- 5 a.m 120 02-01-2012 ------- 1 p.m 80 02-01-2012 ------- 9 p.m 140 (aft. Blood trf)
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TPR flow sheets (Respiration Charting)

Marking in Numeric (10 to 160) Highlight Normal line with redline Used BLACK Ball Point for marking Comments for special marking
Example: On admission After medication After blood tranfusion
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TPR flow sheets (Temperature Charting)

DO NOT DO this .? Multicolor marking only used BLACK Ball pen Bold marking for LINE (______)and DOT (.) Comma like marking (,) Dirty marking Pencil Marking

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Multi color marking

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Multi color marking

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TPR flow sheets STOOL, URINE, B.P, Wt.)

) URINE ()
STOOL ( B.P

(120/80 mm/Hg) Weight... (60 Kg)

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B.P Charting
Marking in Numeric (10 to 210) Highlight Normal line with redline Used BLACK Ball Point for marking Comments for special marking
Example: On admission After medication After blood tranfusion
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P.M & A.M Not Clear???

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Good Work if used scale ??

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Multi color entry , used scale??

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Normal B.P Charting

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Blood Sugar Papers

Must be place in time sequence Always used LAB FLOW SHEET of PIMS If Required to Maintained Hourly bases manual make it as follows DATE TIMERBSFBSINSULINENAME With Initial

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Blood sugar Charting ..???

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Class Activity Blood Sugar Papers

Take out your white paper Make a rows and column for sugar charting Fill the readings as follows :

01-01-201210:00 ->FBS200regular insulin 5 units, s/c , sig/Initial 01-01-201202:00 RBS300NPH insulin 10 units, s/c , sig/Initial
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Blood Sugar Charting

DATE TIME FBS mg/dl INSULIN NAME RBS (Type, WITH mg/dl units, INITIAL route,time) --NIL RN,NOMI WG NOMIWG Regular, 4 --RN,NOMI units , S/C WG (6:10) NOMIWG 350 Regular, 10 RN,NOMI units ,S/C WG (14:10) NOMIWG 54 Nomi WG ACI

01-01- 6:00 2012 a.m. 02-01- 6:0 2012 a.m0 02-01- 14:0 2012 0
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100

200

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Medication Sheet
Must be place in time sequence Write with BLACK ball pen
Date Age Sex Room Date of Admission Department Surgeon
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01/01

02/01 6 a.m NO

Tab. Sofvasc 5 mg,1 X B.D Dr. signature

6 a.m NO

6 p.m NO

6 p.m NO

RN, Nomi WG

NO

01
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Medication Sheet
If found special issue related to medication write in nursing notes Example: Patient was not given Tab. Sofvac 5 mg, at 6 a.m due to severe vomiting therefore was given at 8 a.m. Dr. ABC informed. RN Nomi WG

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Unidentifi ed Name

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Unknown Dr???

Tick Mark ??
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Empty..??

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Time in not clear..??

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Do not cross the entry write for Stop / hold..

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Out of field Entry

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Not reliable..??
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Not reliable charting..??

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Not reliable charting..??

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Not reliable charting..??

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Improper Entry

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History Sheet
Must be place in time sequence Write with BLACK ball pen

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Date Age Sex Room Date of Admission Department Surgeon

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History Sheet
Must be read by all nurses Chief Complain Present Illness Past Medical history Social History (Occupation, Habits) Family History Systemic review (EyesEarCardiac RespiratoryGastrointestinalGenitoUrinaryObs,Gye,Bone, joint, Muscles, Nervouse Allergies Date, Attending Physician _______
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History Sheet
If found any special issue in History sheet much be noted in nursing Notes Example: Patient history was taken by Dr. Abc shows in social history that he is a habitual smoker , smokes 20-50 Cigarette / day. Patient was instructed not to smoke in the hospital boundary, RN, NomiWG
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Physical Examination
Must be place in time sequence Write with BLACK ball pen
Date Age Sex Room Date of Admission Department Physician
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Physical Examination
Must be read by all nurses HT, WT, T, P, R, BP General Eyes, ear, nose and mouth, neck, chest, breast, heart, lungs back, abdomen, lymph, geitalia, rectal, extremities, neuromuscular, skin, working diagnoses Date, attending Physician____________
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Doctors Orders
Must be place in time sequence Write with BLACK ball pen
Date Age Sex Room Date of Admission Department Physician
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Doctors Orders

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Doctors Orders
Special Issue Must be noted in nursing record .

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Doctors Orders

Request Dr. respectfully to fill it

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Doctors Orders

12:30 M.D RN, NomiWG

Must be fill by nurses

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Date time and Dr. entry field Empty

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Empty..??

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Not Clear ..??

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No Dr. Name ??? Date..?? No Date and time

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Wrong Entry ??? Empty..??

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Consent???

Name and CNIC #...???

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Pt. Consent on Doctor Sheet not Legally Acceptable..???, Attendant Name not Clear, Time not clear????
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Progress Notes
Must be place in time sequence Write with BLACK ball pen
Date Age Sex Room Date of Admission Department Physician
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Must be read by Nurses and write special issue in nursing notes

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Excellent Notes..

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I/O charting
Must be place in time sequence Write with BLACK ball pen
Date Age Sex Room Date of Admission Department Physician /Surgeon
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I/O charting
ORAL INTAKE PARENTERAL TYPE TIME AMOUNT TIME AMOUNT

URINE STOOL OUTPUT N/G TUBE OTHER

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TIME TIME TIME TIME

AMOUNT AMOUNT AMOUNT AMOUNT

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I/O charting
9 am
250 ml

9 am

N/S Flagyle

500ml 100ml 100 ml

100ml/hr 100ml/hr 100ml/hr

10 am 10 am 11 am 250 ml 11 am 12 am 12 am 01 pm 250 ml 01 pm 750 ml

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Novidate

700 ml
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I/O charting
9 am 10 am 11 am

9 am

URINE N/G OTHER STOOL

30ml 100ml

10 am 11 am 800ml 12 am

Pass

12 am
01 pm

01 pm 200ml 1030 30 ml
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Pass 100ml
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(TOTAL Absorbed=420)
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Out of field/wrong charting

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Nursing Record
Must be place in time sequence Write with BLACK ball pen
Date Age Sex Room Date of Admission Department Physician /Surgeon
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Nursing Record

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Nursing Record
DATE TIME 01- 11:00 01- a.m. 2012
01-01- 11:00 2012 a.m.

TREATMENT Inj. Laxis 40 mg I/V State

Tracheostomy

CLINICAL OBSERVATION URINE output 1000 ml RN,NOMIWG NOMIWG

POST OPERATIVE NOTES: Patient Received from OT. At 11:30 a.m having GCS 15/15, DR. ABC Advice for NPO TFO,. RN,NOMIWG NOMIWG 96

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Methods of Documentation
1. 2. 3. 4. 5. 6. 7. 8. 9. Source-oriented records Problem-oriented medical records PIE charting Focus charting Charting by exception Case management model Computerized documentation Electronic medical records (EMRs) Narrative charting
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Date/Hour 2/11/08 0900

Focus Pain

09:15

//

Progress Notes D: Guarding abdominal incision. Facial grimacing. Rates pain at 8 on scale of 0 10 A:Administered morphine sulfate 4mg IV.
R:Rates pain at1states willing to ambulate

0930

//
(D) Data (A) Action (R) Response

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Difficult to Read ..??

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Difficult to Read ..??

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OUT of Field but Good Work

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Not Acceptable Nursing Notes

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Patient complain of bleeding from Any site of body???

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Out of field Entry???

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Wrong entry, and unclear data signature unidentif

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Out of field entry..??

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CN Name Not Clear..??

GOOD WORK
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Out of field Entry

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Unidentifiable ???

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References
Will be available on request..

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