Methods of Documentation Traditional (source oriented client record) Problem Oriented Medical Record (POMR) -SOAP -PIE -Focus DAR Charting by exception
Documentation NN (nurses notes) best assessment of pt. care. Most used section of the medical record in legal cases Documentation or Charting is a skill Record of pt.’s condition, activities and events that occurred to the PATIENT. Not a diary of your activities. Includes Subjective & Objective info
Documentation Chart facts, not your opinion Use quotations if pt. said it. Be specific!! Using nonspecific terms implies doubt about your knowledge. i.e. appears/seems/tolerated well etc. In most cases when care or observations are not charted it means it wasn’t done ABC’s: Accuracy/Brevity/Completeness
Guidelines for Documentation: Content Focus on pt. Not a novel or essay Use short sentences Abbreviations Symbols Don’t need to use word pt.
Guidelines for Documentation: Timing Chart as soon as possible after care/observations NEVER chart what you plan to do Date & time each entry in the margin
Guidelines for Documentation: Format Use forms as per agency policy(i.e. flow sheets, graphic sheet, NCP, progress notes) Follow agency guidelines regarding color ink, approved abbreviations, format of time (i.e. military/standard) Write LEGIBLY-questionable info implies doubt suggests you lack reasonable knowledge NEVER skip lines!! Use correct grammar/spelling
Guidelines for Documentation: Accountability Record is permanent Sign full name and title No erasures Do Not write ERROR for a mistake Single line thru mistake, print “Mistaken Entry” or ME (if acceptable) above or next to mistake, enter correction, initial & date per policy
Guidelines for Documentation: Confidentiality Students only use patient initials on assignments Only caregivers need to know info in chart Follow facility policy for pt. review of chart.
Other Guidelines for Documentation Hospitals- computers Home care- laptops Telephone orders