1. Documentation

2. What Is It? Written record of everything done for a patient
Medications
Treatments
Activities
Education
supplies

3. Purpose Accreditation Reimbursement Legal Communication
To prove meeting prescribed standards
Reimbursement
To show what was used
Legal
Shows condition of patient before, during and after treatment
Communication
Within the health team

4. Special Considerations
Confidentiality
Only for those with “need to know”
Must be accurate and thorough
Must be legible

5. Characteristics Factual Accurate
Describe findings, not what “seems” or “appears”
Use exact patient statements, put in “ ---”
Accurate
Precise measurements
No unnecessary words
Only pertinent details
Correct spelling

6. More Characteristics EACH ENTRY MUST BE: Timed Dated Signed
At the time of activity **
Dated
Signed
By the person recording
**exceptions:
after shift
Team effort

7. Signatures First name or initial Full last name Title (ADNS)
At least once per page
Then may use initials
Signature
Initials
S.Manning, RN, MSN SM

8. Still more characteristics
Completeness
Thoroughly describe events using details of
Quality
Quantity
Duration
Measurements
Rating scales

9. yet more characteristics
Current
Up to the minute
Don’t ‘wait til later’
Organized
Use a logical method
Make & review notes before writing in record

10. Legalities NEVER: ALWAYS Erase use white-out scratch or scribble out
Omit critical commentary
Completely record FACTS
Record clarification efforts
Write legibly, use black ink
Correct errors promptly

11. IMPORTANT
If it isn’t written, it wasn’t done

12. Malpractice Issues Incorrect time of when events occurred
Not recording verbal orders
Not getting verbal orders signed
Charting actions in advance
Documenting incorrect data

13. Types of Records Facility designates which format of documentation
SOAP
Subj, obj, assess, plan
PIE
Plan, implement, evaluate
DAR
Data, actions, responses

14. Discharge Planning Begins at time of admission
Must educate the patient
Throughout hospital stay
Diet, meds, treatments, rehab, community resources
Continuity between health teams

15. End of Shift Reports Report facts Obj & subj data
Info about family, prn
Responses to care or treatments
Occurrences

16. Telephone or Verbal Orders
Listen carefully
Write down on notepad
Ask questions if necessary
Read back to physician
Document on order page
Sign after order:
T.O. Dr.Fry/N. Nurse, RN
V.O. Dr. Oar/N. Nurse, RN