DocuNotes: Clinical Pocket Guide to Effective Charting

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by Rebar RN MSN MBA FNP, Cherie

The popular Davis's Notes format makessure that you always have the informationyou need close at hand to ensure yourdocumentation is not only complete and thorough, but also meets the highest ethicaland legal standards. And, the very firstTab reviews the terminology essential tocommunicate effectively in writing withdoctors, other health care professionals,and staff. It also delivers all of the features thatDavis's Notes users rely on Read more Read less.

Credit offered by NewDay Ltd, over 18s only, subject to status. See all free Kindle reading apps. Don't have a Kindle? Davis Company; 1 edition 3 April Language: Be the first to review this item Amazon Bestsellers Rank: Share your thoughts with other customers. Write a customer review. Most helpful customer reviews on Amazon. This was recommended by my clinical instructor and I couldn't be happier that I purchased it. One of the most difficult thing I have found as a nursing student is documentation Worried about who will care for elderly mother and son; noted to be crying softly and praying the rosary.

Call placed to social services department to discuss options for care for elderly mother and son. Educated client about function of social services, and that they are an appropriate resource for assisting clients in finding answers to concerns such as hers. Apply TED hose per orders; will continue to monitor. Two hours later, client still with discomfort upon dorsiflexion of LLE. Educated client about function of TED hose, and the importance of continuing to wear them while hospitalized.

This is a statement of the immediate focus of the plan of care. Usually this will be the nursing diagnosis. Cortez could include several different FOCUS entries by a nursing professional delivering bedside care. The following examples are by all means not comprehensive of all FOCUS notes that could be constructed from this scenario. Head pain related to hypertension. Anxiety related to family concerns. LLE pain related to dorsiflexion.

Fifteen minutes later, client still with discomfort upon dorsiflexion of LLE. Will continue to monitor. Cortez could include several different PIE entries by a nursing professional delivering bedside care. The following examples are by all means not comprehensive of all PIE notes that could be constructed from this scenario. PIE charting is generally not used by medical providers of care such as NPs.

Fifteen minutes later, client still with slight discomfort. For example, was the client eating, walking, lying in bed, watching television, or doing some other activity? Physical Assessment for specific information. What is different about this assessment than the last time the nurse observed the client? What treatment plan is needed at this time? Cortez could include several different SBAR entries by a nursing professional delivering bedside care. The 20 21 following examples are by all means not comprehensive of all SBAR notes that could be constructed from this scenario.

States headache is 6 of 10 on a scale. Admitted for monitoring and hypertension following car accident; T Other assessment information would be noted here, such as repeat vital signs. Tylenol ES mg given per order. Worried about who will care for elderly mother and son. Admitted for monitoring and hypertension following car accident. Crying softly and praying the rosary. Pain elicited upon dorsiflexion of left foot. Applied TED hose per order; will reassess for comfort in 15 minutes.

It can include data gathered via observation, auscultation, palpation, and percussion. If a bedside nurse is providing an assessment, it may include a nursing diagnosis. If a nurse practitioner is making the assessment, it will include a medical diagnosis.

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The plan to address the concern. The nurse practitioner NP will use this section to write pharmacological interventions, diagnostic testing, and other orders, such as the type of diet the client should have and the activity level the client is allowed to observe. With the SOAP format, information is generally brief and targeted at singular problems if written by a nurse at the bedside. Cortez could include several different SOAP entries by a nursing professional delivering bedside care. The following examples are by all means not comprehensive of all SOAP notes that could be constructed from this scenario.

See basic examples that follow: States headache is 6 of 10 on a 1—10 scale. Noted to be crying softly and praying the rosary. Need for social service intervention. Noted facial grimace when dorsiflexing left foot. In nursing documentation, the SOAP notes may be very short and directed at specific incidences in time during which the nursing professional delivers bedside care.

Tylenol ES, mg, ordered by Dr. Social services to be called. TED hose ordered by Dr. Applied TED hose per orders; will continue to monitor. Tolerated application of hose without discomfort; states that hose feel comfortable. This involves any changes that need to be made to the plan of care, if evaluation demonstrates that interventions were not successful. Twenty minutes later, client reports pain is now 7 of 10 on a 1—10 scale.

Chaplain services offered; client agreed to talk with chaplain. States TED hose are very tight and uncomfortable. Then, we will document it in all four formats. For purposes of this example, we will focus only on the information contained in the following paragraph, assuming that regular and complete documentation has preceded this situation.

Kirby is a year old businessman who was admitted to the hospital with pneumonia. His vital signs have been stable this morning. This morning, he ate all of his breakfast and walked to the bathroom with the help of a nursing assistant. Kirby currently has a headache, which he rates as a 7 on a 1—10 scale. He thinks it started after he read too much without his glasses. Upon physical examination, the nurse notes nothing unusual. Thirty minutes later, Mr.

Kirby says his headache is better and is now a 2 on a 1—10 scale. The nurse lets him know to use the call light if the headache returns or he has any concerns or needs. Narrative 11 June , Vital signs stable see flow sheet. Physical examination assessment unremarkable. States has headache of 7 on 1—10 scale due to not using glasses when reading. Tylenol, mg, administered as ordered.

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Nurse, RN 11 June , States headache is now 2 on 1—10 scale. Instructed to use call light if headache returns or develops other concerns. Reports headache of 7 on 1—10 scale. Therefore, another SOAP note would be needed to follow up. States headache is now a 2 on 1—10 scale. Because components of the DART note may occur at varying times, the nurse can select only the components exercised at one time.

For example, the previous note would likely read like this with correct times inserted: States headache of 7 on 1—10 scale. Has been admitted to hospital with diagnosis of pneumonia. Has been reading without his glasses while hospitalized. New diagnosis of diabetes; here to establish. Went to ED for kidney stone treatment. During stay, an Accucheck revealed a blood sugar of Snider to establish for diabetes care.

Client was unaware of diabetes; reports no symptoms whatsoever leading to this diagnosis. Other than normal colds and viruses, he has no remarkable past medical history. Mother is 68, still living and in good health. Father is 70, still living and in good health with only hypertension since age 62 managed with medication. Nonsmoker, non-user of recreational drugs. Works as a banker. Lives with wife and two young children.

Denies anxiety and depression. Denies eye pain, tearing, redness, swelling, discharge, changes in vision. Denies abdominal pain, changes in bowel habits. Denies palpitations SVT controlled with Cardizem , changes in temperature of extremities, swelling and edema. Denies ear pain, congestion, sore throat, mouth lesions or sores. Denies blood in stool, denies knowledge of swollen glands. Denies changes in neurological status, denies changes in strength and coordination of extremities. Denies muscle or bony pain. Denies shortness of breath and coughing. For seasonal allergies, denies history of risk factors for HIV.

Denies knowledge of enlarged thyroid has been tested for hypothyroidism periodically due to family history , denies excessive thirst. Denies skin rashes or sores. Accu-check by nurse reads Appears relaxed and at ease. Vessels within normal limits. Can hear whispers accurately through each ear.

No pain in either ear. Nasal mucosa pinkish—no current drainage. Occlusion of each nare reveals no congestion of opposite side. Client has no difficulty smelling various odors with accuracy. Mucous membranes moist, throat pink with no streaking or exudates. No nodes in cervical or axillary areas.

Lungs clear to auscultation bilaterally. No wheezes, rales or rhonchi noted. Abdomen obese; soft, nontender on palpation. Feet without lesions or ulcers; no breakage in skin. Nails are trimmed well. New diagnosis, type II diabetes Plan: Migraine headaches almost daily for 3 months. Has had a migraine almost every day for the past 3 months. States has had migraines in the past, but not this often. Has taken Tylenol without relief; sometimes Excedrin helps. Generally she just goes to bed and turns out all the lights, but this is starting to interfere with her part-time job schedule as a librarian.

Headaches always associated with nausea; occasionally she has vomited as well. Migraines in the past since age 22 only 1—2 annually. Follows yearly for PAPs with Dr. Td last received in after stepping on nail. Mother and father both alive and in good health. One brother, 35, in good health. Drinks 1—2 alcoholic beverages weekly. Works part time as a librarian. Enjoys camping with her boyfriend. Sexually active since age 19—total of 3 partners. States she was tested for HIV in after boyfriend 2 was unfaithful—test was negative.

No unprotected sex since that time. Denies urinary frequency and urgency, denies pain on urination, denies changes in urinary habits. Denies palpitations, changes in temperature of extremities, swelling and edema. Denies ear pain, nasal congestion, sore throat, mouth lesions or sores. For seasonal allergies, denies history of risk factors for HIV other than when she was tested and shown to be negative. Denies knowledge of enlarged thyroid, denies excessive thirst. Appears anxious and concerned about physical symptoms. Short, shiny, well-groomed hair with no baldness noted.

Scalp normal—no overt dryness or flaking. No sinus tenderness, scalp tenderness on palpation. No trapezoid or sternocleidomastoid tenderness noted. Neck with full ROM. Nasal mucosa pink—no current drainage. Can state date, time, and location. Can distinguish ammonia from perfume without difficulty. Equal strength when biting down. Sensation intact via touch test with filament. Facial nerve intact—equal response when raising brows, smiling, showing teeth, and puffing cheeks; strength equal with eyes closed; bone and air conduction equal.

Can easily hear whispered voices. No strange tastes noted or reported. No involuntary movements noted; gait steady without limping. Easily sits and stands. Can walk on heels and toes, can hop on either feet. No difficulty with deep knee bends. Romberg test negative for drift. Responds to all touches to medial and lateral extremities; can identify sharp and dull sensations, vibratory sense intact bilaterally. Likely migraine headaches Plan: Zomig tablets, 5 mg, 10—1 po within 20 min of headache onset.

Follow up 1 week after CT scan for test results. Referral to neurologist if any CT scan abnormalities. Brown, FNP, RN, 11 June Electronic Records Much like the benefit of template charting, utilization of electronic records or computerized charting allows the nurse to quickly record information about the client. Numerous types of computerized charting software are available.

Some are tailored to physician or primary care provider use, some are geared toward nursing care, whereas others target various additional members of the ancillary health-care team. Additional software packages serve facilities in which multiple disciplines document on the same client, such as when physicians, nurses, therapists, and social workers use the same documentation system in hospital settings. Not only does electronic documentation speed up the documentation process, it also helps to unify documentation by providing fields that must be filled in each time the nurse inputs data. Entry for electronic records can be accomplished in a variety of ways.

Some programs use keyboards, where the nursing professional types in information, much as one would type a letter on a computer. Other electronic systems use voice recognition, where the nursing professional is able to dictate into a microphone, and the program translates INTRO INTRO that dictation into a generated record, such as a progress update or a documentation of treatment or procedure. Continuity of documentation is as important as continuity of care, and electronic record-keeping allows the nurse to demonstrate reliable, consistent documentation in this venue.

Important guidelines exclusive to electronic record-keeping include: If an individual is able to log in under your credentials, he or she can document as if that person were you. This is illegal but could be very difficult to prove if you have voluntarily divulged your user name or password to someone else. Leaving yourself logged on could allow someone to document as you.

Logging off is very important, even if you suspect you might be stepping away from the computer for just a moment. Things happen quickly, and if you are unable to return to the computer in short order, it is very easy for someone else to use your user credentials on that system. Privacy in computerized charting is just as important as in handwritten documentation. People without a need to know should not have visual access to client names on the computer screen. Therefore, document in a location where people are not looking over your shoulder. It is important that others who are not authorized to know about the client are not able to hear what you are recording.

Documentation is a reflection of the professional care you provide and should read as such. When nurses are too brief or casual in their documentation, document subjectively, or omit key portions of care that was delivered, it leaves them open to legal action for claims of negligence or malpractice. These words serve as a powerful reminder that everything you do in the line of duty, from assessing and planning care, to delivering the care, to documenting it, is critical.

These numbers should act as a powerful motivator for you to make sure that your documentation is as complete and thorough as possible. In this tab, you will find examples of common legal documents that the nurse may need to complete or witness. It is very important that accurate documentation about any of these documents occurs and that the nurse understands these types of legal situations. Also, ethical issues are often tied to legal concerns and often call for additional critical thinking in both your decision-making process and your documentation.

In this tab, there is a framework to assist the nursing professional in considering implications of ethical issues, making decisions, and then documenting. Legal Terminology As the nursing professional documents, it is helpful to have an understanding of specific legal terminology. This does not mean that these terms are to be included in the medical record, but rather that the nursing professional is mindful of legal considerations and how appropriate documentation serves to represent comprehensive, individualized, appropriate care that was provided to a client.

Types of advanced directives include: Assault can also involve making gestures that are considered threatening, even without actual physical contact. Battery involves physical contact that is intended to injure another person. False imprisonment occurs when a client is intentionally confined to either his or her room or with restraints, without legal authority. Informed consent is the practice of making the client aware of all treatment options, including the benefits and risks associated with these choices, as well as the benefits and risks associated with rejecting the treatment options.

The primary care provider must provide information to the client during the course of obtaining informed consent; the nursing professional may witness the document indicating that the client has given informed consent. Libel involves defamation in the form of writing. If the nursing professional writes or records something about a client that is defamatory, it can be considered libel. This is the reason that objective, clear, concise, and accurate documentation is so important.

Malpractice involves doing something that should not have been done, or not doing something that should have been done, which resulted in 36 37 injury to the client. As this relates to nursing, malpractice means failure to provide the standard of care that a reasonable, prudent nurse would have provided under the same circumstances, or performing an action that a reasonable, prudent nurse would not have performed under the same circumstances.

Negligence involves not doing something that should have been done. As this relates to nursing, negligence means failure to provide the standard of care that a reasonable, prudent nurse would have provided under the same circumstances. Failing to document appropriately also falls under the category of negligence. Restraints are means by which clients are contained. There are physical restraints, such as chest-vests, soft or leather wrist or ankle restraints, lap belts, and mitten restraints, and there are chemical restraints such as medications that cause clients to become more compliant.

Restraints can be medically ordered, with the order being carried out by the nursing professional; however, as a nurse, you must observe the many legal requirements for monitoring and documentation of the restrained client. If restraints are used inappropriately, or in the absence of a medical order, the client could be considered falsely imprisoned. The following table, from the Joint Commission , demonstrates a framework for application and monitoring of restraints.

It is important to continually document during each of these phases as they pertain to the individual client. The nursing professional should also consult facility policy. Seclusion involves placing a client, against his or her wishes, in a room or location in which the client cannot leave. If seclusion is used to promote client safety, the same standards applying to restraints see above are to be observed. Slander involves defamation in the form of speech. If the nursing professional says something about a client that is defamatory, it can be considered slander.

Order obtained from licensed independent provider LIP within 1 hour of initiation of restraints or seclusion. Occurs every 4 hours until adult released from restraint or seclusion. Occurs every 8 hours until adult is released from restraint or seclusion. Order obtained from LIP within 1 hour of initiation of restraints or seclusion. Every 2 hours for children ages 9 to 17 years until the child is released.

Every hour for children younger than age 9 years until the child is released. Every 4 hours for children 17 years of age and younger until the child is released. This does not mean that these terms are to be included in the medical record, but rather that the nursing professional is mindful of ethical considerations and how appropriate documentation serves to represent comprehensive, individualized, appropriate care that was provided to a client.

The client has the right to decide if he or she desires to take part in certain healthcare practices, or to refuse them. Beneficence is the duty to do good to others. As a nursing professional, you are ethically bound to promote good for your clients. When practicing beneficence, it is important to remember to avoid paternalism. Fidelity involves doing what one has promised. As a nursing professional, you are ethically bound to keep your word and commitments to your clients. If you say you will do something, you are to do it.

Justice reflects equitable distributions. This can be interpreted as providing equity in the way that a nursing professional cares for a client, as well as equally distributing potential benefits and risks when explaining health-care options. Justice represents the fact that discrimination, exploitation, and unfair treatment to clients is not appropriate. For example, if the client states that he or she is uncomfortable having the nurse perform a task, such as the insertion of a nasogastric tube, the nurse can utilize the ethical principle of justice to explain the benefits of the procedure versus the risks.

Nonmaleficence is the obligation to do or cause no harm to another individual. This can be interpreted as physiological, psychological, social, cultural, or spiritual harm. This does not include parents or guardians who make choices for their minor children, but rather addresses adults who make choices for other adults who are otherwise able to make their own decisions.

For example, if a client decides he does not want to take chemotherapy, but his wife decides that he is going to take the treatment and the primary care provider permits the chemotherapy to be ordered , paternalism has been exercised. Respect involves showing others that their rights and decisions are acknowledged. Veracity is the obligation to tell the truth. Again, this information does not need to be specifically documented in the medical record, but the objective documentation of the situation should represent appropriate ethical decision making according to this or another ethical decision-making framework.

Recognize an Ethical Issue 1. Is there something wrong personally, interpersonally, or socially? Could the conflict, situation, or decision be damaging to people or to the community? Does the issue go beyond legal or institutional concerns? What does it do to people, who have dignity, rights, and hopes for a better life together?

Get the Facts 3. What are the relevant facts of the case? What facts are known? What individuals and groups have an important stake in the outcome? Do some have a greater stake because they have a special need or because we have special obligations to them?

What are the options for acting? Have all the relevant persons and groups been consulted? If you showed your list of options to someone you respect, what would that person say? Which option will produce the most good and do the least harm? The ethical action is the one that will produce the greatest balance of benefits over harms. The ethical action is the one that most dutifully respects the rights of all affected. What options are fair to all stakeholders? Fairness or Justice Approach: The ethical action is the one that treats people equally, or if unequally, that treats people proportionately and fairly.

Which options would help all participate more fully in the life we share as a family, community, society? The ethical action is the one that contributes most to the achievement of a quality, common life together. Would you want to become the sort of person who acts this way e. The ethical action is the one that embodies the habits and values of humans at their best. Make a Decision and Test It Considering all these perspectives, which of the options is the right or best thing to do? If you told someone you respect why you chose this option, what would that person say?

If you had to explain your decision on television, would you be comfortable doing so? Act, Then Reflect on the Decision Later How did it turn out for all concerned? If you had to do it over again, what would you do differently? A framework for ethical decision making. Retrieved July 1, from http: The nursing professional does not have to identify the situation as an ethical one; the objective documentation is evidence enough to demonstrate what is being recorded.

Advance Directives Clients have the right to determine what happens to their bodies and are to be allowed to participate in decisions regarding their health care. The client creates them, usually with an attorney, when the client is of sound mind and judgment to 42 43 declare what he or she wishes to happen in the future if he or she is impaired and cannot verbalized those choices. The client has the autonomy to change his or her advance directives at any time the client is competent and able to make decisions for him or herself.

For example, a client may want to change the person who is designated to make health-care decisions for them, called a Durable Power of Attorney or Health Care Proxy. As long as the client is of sound mind and ability, he or she can make this change at any time. The client does not have to state a reason for wanting to make changes to his or her advance directives. Advance directives come in several formats. Some clients may have all forms of advance directives; others may only have one or two.

The most common components of advance directives include: This is a document that details the treatment or lack of treatment that a client desires during end-of-life care. Clients may desire one type of care, but not others; they may request all of the care available often called heroic measures or specify that no such measures should be instituted.

A living will often addresses whether a client desires to have, or to decline, the following examples of interventions: This is an individual who is appointed by the client, when of sound mind and ability, to serve as the decision-maker for health-care decisions, if the client is incapacitated. This is not to be confused with a General Power of Attorney, which gives another individual power to sign for general purposes, such as banking and real estate. These orders state that the client does not wish to be revived.

Sometimes another department has completed this before the client reaches the unit, but you should still confirm that it has been documented. Information to document includes: If a health-care provider chooses to not follow an advance directive, various legal implications, such as assault, battery, negligence, or malpractice can ensue. For example, consider that a client has an advance directive stating he is to be DNR. When the client codes, a health-care provider decides to willfully ignore the DNR status and starts providing advanced cardiac life-saving techniques.

Incident Report An incident report is a document that is completed when an incident occurs that has an adverse outcome, such as an injury incurred while hospitalized, such as from a fall. However, information contained on incident reports of different facilities 44 45 will be very similar. You will use the incident report to record information such as: Date and time of incident. Individual s involved in incident. Situation of incident how it occurred. Adverse effect of incident, such as injuries sustained.

Individuals notified, including supervisor, treating physician, family member. It is also very important that you not document that you have completed an incident report. The charting should remain very objective and address only the facts of the situation. The nature and purpose of a proposed treatment or procedure. The risks and benefits of a proposed treatment or procedure. Alternatives, regardless of their cost or the extent to which the treatment options are covered by health insurance. Although the burden of disclosure is on the treating physician, the nurse can assist in the informed consent process in the following ways: If a client is not alert and oriented, obtaining informed consent at that time is not appropriate.

If all of the appropriate conditions for informed consent have been met, the nurse should document the following: The nursing professional is not witnessing whether the client understood the information this burden is placed on the physician , but rather that the actual client is the one who has signed the informed consent form.

It is always possible that the client will refuse to sign the informed consent form, even after thorough dialogue with the physician. If all of the appropriate conditions for informed consent have been met see earlier , the nurse should document the following: The nursing professional is not witnessing whether the client understood the information this burden is placed on the physician , but rather that the actual client is the one who declined to sign the informed consent form.

Withdrawal of Treatment Withdrawal of treatment is agreed upon when two physicians have determined that there is no hope for recovery and that further medical intervention is futile. Family members are consulted in this process, and decisions are made regarding termination of treatment.

The nursing professional is often called upon to record information that indicates that treatment is being withdrawn. It is important that the nurse also document the decision to discontinue treatment and the content of the accompanying conversations of such in the medical record. Aim to establish an agreement within the meeting among the members of the team to withdraw life-prolonging treatment. Members of the multidisciplinary team present during the meeting. Is there an agreement on the need to withdraw treatment?

Consider Organ Donation 2. Is there a room where the family can be left alone? Is an interpreter required? Family Care Meeting Date: The goal is to ensure that the family fully understands the need and process of withdrawal of treatment. Full explanation of futility of treatment explained? Clinical plan shared with family members? Decision to withdraw treatment agreed by family members? Does the family require time? Explanation of the process of events following withdrawal of treatment is explained without time scales.

Withdrawal of Treatment The goal is to ensure that everything is ready for withdrawal of treatment. When and where is treatment to be withdrawn? Secretions are not a problem Pain Aim: Client is pain free Agitation Goal: Clients does not feel nauseous or vomitous Mouth care Goal: Client is comfortable and safe, with regular positional changes Psychological support Goal: Verification of Death Date of death: One of the key principles to remember is that you should include information that is concise, descriptive, and informative.

There are some cardinal rules to follow as you document. Although they may sound basic, they are of critical importance as you put pen to paper or fingers to keyboard. Your documentation reflects your professionalism and is a true representation of the care you provide as a nurse.

Double check to make certain that the paperwork within the chart belongs to the same client; it is not unusual for papers to get shuffled between charts if people are not careful. It is impractical and inappropriate to try to backload your documentation at the end of the shift. Be certain to document in a timely fashion after care is provided so that you stay on top of this important task. It is also important to timely document so that any other health-care provider who needs to reference the medical record can read an up-to-date account of the assessment of the client and the care that has been provided to that point in time.

When documenting in a paper-based chart, it is critical to write legibly. Other caregivers need to see exactly what you did, when you did it, and how the client responded. In rare and unfortunate instances that documentation may be called into question during legal pursuits; it is of the utmost importance that you are able to read your own writing and explain what you did. Multiple ink colors make documentation difficult to follow and do not look professional. Some institutions require only one color, such as black.

Again, it is of critical importance to represent accurately the care that was provided. As a nurse, you want people to reflect the professionalism of the services and care that you provide. Inaccurate spelling and grammar detracts from that professionalism. If necessary, keep a pocket dictionary handy. When using computerized documentation, run a spell-check before submitting the records. Leaving blank lines and spaces at the end of lines allows other people to chart after you and makes it appear that you were responsible for that portion of the charting.

To protect yourself, use all lines available without skipping, and line through any unused portions. Sometimes, clients explain symptoms in words that are very descriptive. It is important to reflect exactly what the client said by the use of quotation marks. This can also be helpful when documenting comments by the client that are indicative of state of mind or emotion. For example, if the client tells the nurse to leave him alone, the nurse would include in the documentation a phrase such as this: The nurse should never pass judgment on a client or put this type of thought into documentation.

The nurse must strive to record only objective findings, and it is important to note that objective documentation of behaviors, cultural practices, spiritual beliefs, and other pieces of individual assessment information can greatly contribute to the plan of care. The key is maintaining that objectivity and recording only what is observed and what is communicated to the nurse. Personal feelings or judgments of the nurse do not belong anywhere in professional documentation.

We discussed the issues associated with abbreviations in Tab 1. Improper documentation will occur. Sometimes, a nurse will inadvertently document in the wrong chart; other times, the nurse will inaccurately record data. When this occurs, the nurse must amend the incorrect documentation. When making a correction, place a simple line through the inaccurate documentation and initial it.

Do not use white-out or attempt to black out the wrong documentation. Once finished with your correction, continue to record appropriately. What happens when your best intentions go awry and you are not able to document in a timely fashion? This is not uncommon, as sometimes client needs require your full attention and you are unable to document at the time you had anticipated, such as when a code is called.

When this occurs, the best practice is to simply annotate that the entry is late, describe the reason that charting was delayed, and proceed with the objective documentation. Chart was unavailable at ; physician was documenting Proceed to document the pertinent information here.

Synthesizing the Information Documentation Example Three examples of documentation performed for the same client are presented here. Which one would you identify as best reflecting the assessment completed by the nurse? Which is the most descriptive and allows other caregivers to interpret exactly what the nurse observed during the assessment?

Which documentation would you rather have recorded in case something ended up in the hands of an attorney? Undoubtedly, the answer to all three of those questions is Documentation Example 3. Eyes and nose OK. This documentation is missing key details that would provide continuity of care. It is also missing information, which means that it is not representing the accurate portrayal of the full assessment performed by the nurse. Many general statements are included, but the next nurse reading this documentation is left to ask: Even if findings are normal, it is important to record what was specifically inspected, auscultated, palpated, and percussed.

Documentation Example 2 Fair Documentation 11 December , Skin without lesions or breakdown. No JVD, no carotid bruits. Lungs clear to auscultation. Bowel sounds normoactive in 4 quadrants. Radial and pedal pulses present. Capillary refill x 2 seconds. This documentation is clearly better than the documentation found in Example 1, as it includes more detail. Alert and oriented x 3. Skin warm and dry with pink undertones and without lesions or breakdown. Mucous membranes moist; wearing clean dentures.

Lungs clear to auscultation; breathing easy and symmetrical. Abdomen soft and round, nondistended, nontender. Strength equal in upper and lower extremities. Bed in low position, 2 side rails up, call light in reach.

DocuNotes - Clinical Pocket Guide to Effective Charting

In comparison with examples 1 and 2, the nurse has clearly identified pertinent findings about the client, and has included very specific clarifying phrases, such as complete descriptions of heart rate and ease of breathing, as well as notation of the pulses, commentary on extremity strength, and a description of how the client was left. This provides the best basis for continuity of monitoring and care planning. There are two types of situations: Client situations, which include searching, equipment tampering or handling, hostile advances or harassment, information to be passed to media, and photographing.

Health-care providers should always act in strict accordance with state law, as well as facility policy. Searching To search a client for items that are of concern, such as illegal substances, alcohol, firearms, or other weaponry, it is important to recognize that there must be a clear rationale and need for doing so. Hospitals and clinics do not routinely search clients, so there must be an indication present that the client possesses one or more of these items to justify a search.

It is unwise to proceed with a search without the knowledge of another individual.

DocuNotes recommends notifying security so that the nursing professional will not have to search the client alone. The first step in searching is to simply ask the client if he or she has the suspected item in immediate possession. Sometimes, clients are very forthcoming, and the process is not difficult. In this case, documentation is quite easy: Client smells strongly of alcohol, carrying brown paper bag with item resembling a bottle inside.

Nurse, RN Unfortunately, not all situations are this easy. Sometimes clients refuse to allow a search. In cases such as this, it is imperative to notify a supervisor, such as a nurse manager, and security. Facilities may also have policies in place that are specific to their institution, so the nursing professional should contact those individuals listed by the facility.

It is important to not engage the client any further in an effort to secure the substance until reinforcement has arrived. In cases such as this, a chronological record of events must be documented by the nursing professional. It is imperative to keep this information objective, and not condemn the client for not surrendering the item: Nurse asked for client to give her the bag; again, client refused.

Hughes and Patrick on their way to emergency department. Kathy Hughes, nurse manager, and John Patrick, security officer, arrived at emergency department. After unsuccessful dialogue between Mr. Patrick and client, Mr. Reviewed hospital policy with client regarding alcohol, and the rationale for why Mr.

Patrick had to take the bottle. Nurse, RN Equipment Tampering or Handling Clients may purposefully tamper with equipment, or may accidentally hit a switch or button, causing a change in function of the equipment. Education about proper use of the equipment is important in both of these situations, as is documentation that reflects the situation and the teaching provided: Client noted to have removed pulse oximeter from finger and replaced it upside down; client became alarmed when reading showed no saturation on the monitor and an alarm began to sound.

Explained proper placement of pulse oximeter to client and reinforced the need to keep the mechanism on his finger in the appropriate position. Encouraged client to call if he had any questions about the equipment prior to removing or manipulating it. Nurse, RN Hostile Advances and Harassment Hostile advances may include physical or verbal aggression or sexual harassment.

The nursing professional must know how to effectively temper and handle these situations and how to document an accurate representation in the chart about the event. If the client becomes aggressive, there are multiple possibilities for this behavior, such as fever-induced delirium, medication reactions, or a psychiatric crisis.

The nurse must quickly assess the possible causative agent and then take action to protect both client and self. Just as there are numerous potential causes for this behavior, there are multiple potential interventions. The documentation must accurately reflect what took place, beginning with the first assessment of the noted behavior, to the interventions put in place, to the outcome: Discussed rationale for hospitalization.

Docunotes: Clinical Pocket Guide to Effective Charting

Client continued to pull at nurse, and began attempting to climb upon him. Nurse called for assistance; John Smith, RN, responded and assisted to place client in bed in soft restraints. Explained rationale for restraints. Client crying softly in bed, no further attempts to get out or pull on nurse. When documenting a statement that someone makes about a lawsuit, it is important to remain objective, recording only the facts surrounding the situation and the statement made by the client or family member. Client lying in bed reading book.

Nurse, RN Intent to Commit Suicide Intent to commit suicide may come in the form of a verbal statement by the client, behavioral implications that the nursing professional observes, or an act that the client has attempted. Suicide precautions immediately initiated. Green, RN, notified; Security notified. Hammas, RN, supervising client.

Client notified that he will be supervised at all times; client verbalized understanding. Unable to contract for safety at this time; will reassess in ten minutes. Nurse, RN Nonconforming Behaviors In any health-care environment, there is the possibility that a client will engage in nonconforming behaviors. This includes exhibition of violent behavior, and may be noted verbally or in physical manifestation. Although this is likely experienced more frequently in mental health units and in the emergency department, it is possible that this can occur in any facility at any time.

Nursing professionals must be prepared to take immediate action to promote safety of the client and others in the vicinity, and document interventions accordingly. It is important to attempt to communicate with the client calmly and objectively to avoid contributing to escalation of the behavior. Client noted to be pacing up and down hallway. Informed client that I understood he was frustrated but that he was not permitted to behave in this capacity and would need to return to him room.

I stated I would join him and we could discuss what was troubling him. Client began pacing hall again. Other items on desk removed; no other clients in immediate vicinity. Security arrived, escorted client to room. Security is with client at this time. Griffin paged; orders received. Nurse, RN 62 63 Leaving Against Medical Advice Autonomy allows individuals to make choices for themselves, as long as they are of sound mind and ability.

Occasionally, clients will make a choice to leave against medical advice AMA. If a client chooses to leave AMA, the nursing professional must provide: It is important that the client is made aware of the risks of leaving. Documentation should reflect that the nurse has provided this information and that the client has acknowledged understanding of this information.

Many facilities have their own form that clients must sign when choosing to leave AMA. Narrative documentation should include the information provided earlier, as well as pertinent teaching given to the client before his or her departure. Client has chosen to leave against medical advice. Is alert and oriented to person, place, and time, and is mentally clear. Jeffries notified; states client should not leave at this time due to the need for further testing, and must sign out against medical advice if she chooses to go. Client notified of Dr.

No medications ordered by Dr. Nurse, RN Photographing At some point in your career, you may need to obtain written consent from a client to photograph him or her. Other reasons for photography, however, are related to the care of the client and require the intervention of the nurse to secure consent. Some of the reasons to photograph a client in relation to care provided include: In cases such as these, you will generally have to ask the client to sign a specific form that is facility-specific.

In the case of a client who is a minor, the parent or legal guardian will be asked to sign. This form will also need to be witnessed by the nursing professional. Client notified of the need to photograph progression of healing of decubitus ulcer on her right heel. Verbal permission given to photograph. Written permission or consent to photograph signed by the client or parent or legal guardian is preferable to recording verbal permission in the chart. Often, these differences are experienced between physicians and nurses, although the possibility for these encounters to take place between any two or more members of the health-care team is possible.

In this situation, objectivity in documentation is key. You will need to accurately and appropriately reflect the discussion without letting your subjective view of the situation reflect itself in the documentation. Client still with headache. Smith has not returned pages.