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Chapter 23 the nursing documentation

Reading

The patient’s official record is used by all members of the health care team to communicate the
patient’s progress and the current treatment. Therefore, entries in the record must be clear. The chart
also serves as a legal record of the care and the patient’s progress. It is used to determine the
appropriateness and the quality of care being given; therefore, accurately, legibility,clarity. And
completeness are very important.

Type of records

Temporary records

Nursing unit will almost always have a variety of temporary records that are used to facilitate
communication or to maintain for easy accessibility. These are valuable, but they must be recognized as
temporary and should not be the only record of important information about the patient. Although they
are temporary, these records do need to be accurate.

Temporary records may also be placed at the bedside to facilitate carrying out specific
measures. Temporary bedside records that are designed to be discarded in some facilities. For example,
a neurologic assessment flow sheet might be placed at the patient’s bedside to facilitate
documentation. When the flow sheet has been filled out, it is then transferred to the permanent chart.

Permanent records

The Permanent patient record may be a paper chart or a computerized record. In either situation, the
information in the permanent record constitutes a legal and confidential document.

1. “The chart”
A permanent paper record of the patient’s health care is called the “ chart”. This record is the
legal record of care ; it is the proof of the patient’s condition and care in legal proccedings. It
also is proof of care facility, the chart is a means of communication among members of the
health care team in regard to the patient’s condition and care. It is also used to evaluate the
quality of care given. In addition, data from the chart are used for teaching and research.
2. The computerized record
Computerized information systems are used in many health care facilities, and the trend is
toward increasing use. Computerized patient information systems are tipically unique to the
satting in which they are found.

System for organizing content

The two major system for organizing the information in a patient’s record are the source-oriented
system and the problem –oriented record (POR) or problem –oriented medical record (POMR) system. A
facility may use one system or a combination of these two systems to meet its needs and staff
preferences.

All members of the health care team write progress notes about the same problem on the same
in the chart. Both systems contain the following elements :
1. Database. This include the initial physician’s history and physical examination, original
laboratory and diagnostic test results, social and financial data, and the nursing admission
interview. The term database may not be used, but this type of information is part of every
record.
2. Flow sheet. These forms are arranged in columns or graphs that allow information to be
recorded quickly and progress to be monitored with ease. Usually you will use flow sheets to
record vital signs, intake and output, medication given, routine nursing care, although a more
complex parameter, such as patient teaching. Flow sheets facilitate review of information to
determine patterns and trends. Because they do this so effectively and require less time for data
entry.
3. Progress notes . in source-oriented records, progress notes are separated by discipline. There is
one form for the physician’s progress notes, another for the nurses’ notes, and still others for
the notes of others health care groups (physical therapists, respiratory therapists ). Source –
oriented records may use fewer flow sheets; therefore, you may find most information in the
progress notes.
4. Problem list. This list is a combination table of contents and index to the patient’s condition and
progress. Each problem is numbered and titled for easy reference. Titles may refer to medical
diagnoses, patient problems, or nursing diagnoses, depending on the setting. The date when the
problem was initially identified is included, and the problem is resolved, that fact and the date
of resolution are added.

Mechanic of charting

Meeting legal standards

As a legal record, a chart must conform to certain legal standards of legibility, clarity, and accuracy.
All entries in a paper chart must be in ink so that changes are noticeable and the record is
permanent.

Computerized patient records maintain this legal standard by not permitting changes once the
information has been entered into the record. The health care worker can usually edit the note
being composed, but after permanently entering the information in the record, the computer
program blocks any changes. Errors in documentation, blank spaces, legal signatures, time frames,
and privacy are all major legal concerns in documentation.

Errors

If you make an error, draw a single line through the incorrect entry so that it remains legible.
Traditionally the word “ error” followed by initials ( or first initial, last name, and title) was written
above the lined out entry. Recently, some attorneys have suggested that entering the word “error”
may given an uninformed lay person the idea that this means an error was made in care. To avoid
this, include a note as to the nature of the error. This is helpful if the chart is needed in a legal
proceeding. Such a note might read “chatered on wrong chart” or “ mistaken entry “ and your
initials. This notation and the traditional “error” are both legally correct, so follow the policy of your
facility. If it has no policy, the more descriptive notation is preferable.
Documentation errors should never be corrected by erasing, using correction fluid, or
obliterating the firs entry. This may create the impression that the information record was damaging
to the care provider or is being hidden for other reasons. When the mistake can be clearly read, the
situation can be evaluated more readily.

Computer system have individualized approaches to correcting errors. When the error has been
entered, a subsequent note is written to correct or clarity the error.

Space

If you are using the narrative form a charting, chart on consecutive lines and do not leave any blank
space. Draw a single line through any empty spaces to prevent subsequent entries from being made
above your signature.

Signature

When you sign a notation on a patient’s record, use your first initial and full last name followed by
the abbreviation of your position. If you were a nursing student named jane smith, you would sign
the record “J. Smith NS “. In large facility where there is more chance of two individuals having the
same initials, the facility may requite that you sign your full name.

Time

Notations of time and date are important for health care reasons and legal reasons. Time sequences
can be crucial in certain problems.

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