Professional Documents
Culture Documents
Dar
Dar
Introduction
Patient’s records serve many purposes such as:
communication with other healthcare professionals
recording of therapeutic and diagnostic orders
care planning
quality-of-care recording
research
decision analysis,
education,
legal documentation,
reimbursement,
historical documentation
*(Taylor et al. 2005)
Nurses are responsible for ensuring that diagnostic and therapeutic orders are
entered in the patients’ records and implemented. These orders should be written and
signed by the ordering physician.
In-Patient areas
• Time of doctor’s visit and all subsequent visits of the physician
• Written orders of all physicians
• Specimen (s) obtained:
Type of specimen (s)
Time it was obtained
Time it was sent to the laboratory
Reactions, attitude, Moods and Status of the patient
Pertinent subjective observation
Complaints of pain
Discomfort of other attitudes
State of depression; worry, agitation, reaction to
hospitalization or illness.
Objective observation
General Appearance / Changes on:
Respiration
Drainage
Condition of the skin
Edema, etc.
Attitudes / Observation for any signs of:
Depression
Worry
Agitation
Reaction towards hospitalization or Illness
Activity / Type of activity
Nurse’s observation
Position changes as to time
Response and tolerance to activity
Paralysis and degree of limitation of movement.
Focus charting describes the patients’ perspective and focuses on documenting the
patients’ current status, progress towards goals, and response to interventions.
Purpose
Brings the focus of care back to the patient and the patients’ concerns. Instead of a
problem list or list of nursing and medical diagnosis, a focus columns is used that
incorporates many aspects of patient and patient care.
The focus might be patient strength, problem, or need. Topics that may appear in the
focus column include patients’ concerns and behaviors; therapies and responses; changes
of condition; significant events such as teaching, consultation, monitoring, management
of activities of daily living or assessment of functional health patterns.
The narrative portion of focus charting includes DATA, ACTION, and RESPONSE ( D
A R ). The principal advantage of focus charting is in the holistic emphasis on the patient
and his/her priorities including ease in charting.
Objectives
To easily identify critical patient issues / concerns in the progress notes.
General guidelines
Focus charting must be evident at least once every shift.
Focus charting must be patient-oriented not nursing task-oriented.
Indicate the date and time of entry on the first column.
Separate the topic words from the body of notes:
Focus note written on the second column.
Data, Action and Response on the third column.
Specific Guidelines
To document a new finding – when the purpose of the note is to document a new
sign or symptom or a new behavior which is the current focus of care. (These
may be “temporary foci” which do not need to be incorporated on the plan of care
because they can quickly be resolved. Even if you are uncertain whether the sign
or symptom is important, it is valuables to communicate the information to the
health care team.)
To document an activity or treatment that was not carried out – when treatment or
activity in the flow sheet was not provided to the patient or was different from the
standard of care.
To identify the discipline making the entry as well as the topic of the note – when
all members of the patient care team use one patient programs record.
Examples: Social service / financial assistance
Dietician/instruct low fat diet
Physical therapy/crutch walking
To best describe patient’s condition in relation to medical
diagnosis – when the patient’s focus is the pathophysiology rather than patient’s
response to the problem. This happens most frequently in highly technical areas
such as critical care.
Data, Action, Response only contain information related to the focus, none
of the information is extraneous (e.g., asleep, watching TV, visited by
family).
DATA and ACTION are responded at one hour and RESPONSE is not added until
later, when the patient outcome is evident.
RESPONSE is used alone to indicate a care of plan goal has been accomplished.
Example:
ACTION and RESPONSE are repeated without additional data to show the sequence
of decision making based on evaluating patient response to the initial intervention.
Example:
Begin the note with ACTION when the patient’s interaction begins with intervention
or when including date would unnecessary repetition.
DO’s DON’T’s
1991 – RA 7164 (The Philippine Act of 1991) Sec. 27 (a) Art. V states that IV
injection is within the scope of nursing practice.
1993 – Nursing Standards on Intravenous Practice was established.
October 1993 – Training for Trainers for ANSAP Board Members and Advisers at
the Philippine Heart Center.
February 4, 1994 – PRC-BON Resolution No. 08 states that a RN is pohibited
from administering intravenous injections unless he has undergone a special
training.
1994 - PRC-BON Resolution No. 08 also states that any RN without such training
who administered injections to patient shall be held liable either criminally,
administratively, or both.
June 9-11, 1994 – Training for Trainers at Cagayan de Oro City.
May 17, 1995 – Protocol Governing Special Training on the Administration of IV
Injections for RNs adopted ANSAP's IV Nursing Standards of Practice.
June 13, 1995 – Department Circular No. 100.S.1995 was disseminated by DOH.
2002 – Special Committee by ANSAP in collaboration with PRC-BON was
founded.
2002 – RA 9173 (Philippine Nursing Law of 2002) again states that the
administration of parenteral injection is within the scope of nursing practice.
August 25, 2006 – Nursing Standards on Intravenous Practice 7th ed was released
by Association of Nursing Service Administrators of the Philippines (ANSAP).
Philosophy of ANSAP
Definition of IV Therapy
Scope of Practice
ROLE DEFINITION
The IV nurses are registered nurses committed to ensure the safety of all patients
receiving IV Therapy.
Definition of Practice
ETHICO-LEGAL IMPLICATIONS:
Content of Documentation
Responsibilities of a Nurse:
Doing the right thing the first time and all the time.
Chart and document the important parts of the nursing process.
Do’s in Documentations
Review notations before signing them. This helps minimize the need for
subsequent corrections or addenda.
Make all entries at the time of treatment, examination or procedure or as soon
after as possible.
Draw a line through any empty space at the end of an entry or at the bottom of the
page.
Complete all boxes or blanks if forms are used. If no information is available or
an item on the form is not applicable, indicate this in the box or blank so that it is
clear that you didn’t disregard the item.
Make sure the record acknowledges patients complaints and concerns and
indicates that they are taken seriously.
Include clinically relevant information about a complication, error, misadventure,
etc. How the situation was handled administratively does not belong in the
medical record.
Stick to the facts and choose your words carefully if a mishap occurs. Do not
argue your case in the medical record. Defensive entries can damage the
credibility of the entire record.
Use only hospital-approved abbreviations and symbols.
OBSOLETE TERM REASON SUGGESTED PHRASE
conscious & coherent > only for patient's whose > patient oriented to date,
neuro-logical status is time and place
affected and disoriented
vital signs taken > vital signs are already > document if you were not
written on the monitoring able to take VS and why
sheet
afebrile > temperature is included in > if the patient is febrile,
the monitoring sheet, status support it with subjective
can be deducted here and objective cues.
> evaluate effectiveness of
nursing intervention for
fever, include the element of
time
Forbidden Abbreviations
Don’ts in Documentations
Use ditto marks or unapproved abbreviations or initials.
Skip lines or leave blank spaces.
Try to squeeze in extra words at the end of the line.
Use terms with more than one meaning.
Use vague term such as “fair” or “apparently” or “better”.
Record permanent conclusions.
Criticize physician’s judgments or recommendations.
Make defensive notations.
Erase or obscure anything.
Advantages:
Most flexible of all documentation systems.
Training time needed for new staff members is brief.
Other health care team members can review the patient’s progress on a
day-to-day basis.
Can easily present information collected over an extended period.
Helps to decrease charting time when combined with other documentation
devices.
Disadvantages:
You must read the entire record to arrive at the outcome.
Tracking problems and identifying trends in patient’s progress can also be
difficult and time consuming.
Tendency to document everything.
Difficult to retrieve specific information.
Some may be documented briefly, others at length for no clear reason.
Advantages:
Organizes information about each problem into specific categories.
Illustrates continuity of care, unifying the care plan and progress notes into
a full record.
Promotes documentation of the nursing process.
Eliminates documentation of non-essential data.
Most effective in acute care or long-term care settings.
Disadvantages:
Emphasis on the chronology of problems rather than their priority.
Repetitious charting of assessment findings.
Resulting overlap makes it time-consuming to perform and read.
Routine care may be undocumented unless flow sheets are used.
Difficulties may arise if team members fail to update the problem list
regularly.
The considerable time and cost of training new personnel to use the
method may also be an disadvantage.
Isn’t well suited for settings with rapid patient turnover.
PROBLEM-INTERVENTION-EVALUATION SYSTEM
Advantages:
Ensures that your documentation includes nursing diagnosis, related
interventions, and evaluations.
Encourages to meet JCAHO requirements.
Provides organizing framework for your thoughts and writing.
Simplifies documentation.
Promotes continuity of care.
Improves the quality of progress notes.
Disadvantages:
May require in-depth training for staff members.
Re-evaluation of each problem during each shift is time-consuming and
leads to repetitive entries.
Omits documentation of the planning step in the nursing process.
Doesn’t incorporate multidisciplinary charting.
NURSING PROCESS
GATHER DATA
Assessment checklist
• Physical
• Psycho-social
• Mental-Spiritual
• Environmental
• Diagnostic Results
• Vital signs, initial
ANALYZE DATA
Maslow’s Hierarcy
A.B.C.D.
PLAN
Kardex
IMPLEMENT
Implementation
• Medication sheet
• Vital signs sheet
• I.V. fluids sheet
• I & O sheet
• Other special forms
FOCUS CHARTING
Advantages:
Flexible and can be adapted to fit any clinical setting.
Centers on the nursing process.
The format provides cue that direct documentation in a process-oriented
way.
Easy to find information on a particular problem.
Encourages regular documentation of patient responses to medical and
nursing therapy.
Ensures adherence to JCAHO requirements.
Can be used to document many topics without being confined to those on
the problem list.
Helps to organize your thoughts and document succinctly and precisely.
Disadvantages:
May require in-depth training, especially for staff familiar with other
systems.
Requires you to use many flow sheets and checklists.
Can be a narrative note if you neglect to include patient’s response to
interventions.
CHARTING-BY-EXCEPTION SYSTEM
Advantages:
Decreases the time needed to document normal and abnormal findings.
Promotes uniform nursing practice.
Flow sheets lets you easily track trends.
Abnormal findings are highlighted.
Documentation of routine care is eliminated.
Information that has been recorded isn’t repeated.
Disadvantages:
Major time commitment needed to develop clear guidelines and standards
of care.
Doesn’t accommodate integrated or multidisciplinary charting.
May be questioned in court until the system becomes more widely known.
FACT SYSTEM
Advantages:
Eliminated repetition.
Encourages consistent language and structure.
Outcome oriented.
Communicates patient progress to all health care team members.
Permits immediate recording of current data.
Eliminates the need for many different forms.
Reduces the time spent writing narrative notes.
Disadvantages:
Requires major time commitment to develop standards and implement the
system.
Narrative notes may be too brief.
Nurse’s perspective may be overlooked.
The nursing process framework may be difficult to identify.
CORE SYSTEM
Advantages:
Incorporates the entire nursing process into one system.
Groups nursing diagnosis and functional assessment together, allowing
various solutions.
Promotes concise documentation.
Encourages the daily recording of psychosocial information.
Useful in acute care and long-term care facilities.
Disadvantages:
May require in-depth training for staff members who are familiar with
other systems.
Developing forms may be costly and time-consuming.
Doesn’t always present information chronologically.
Progress notes may not always relate to the care plan.