2 Dr. Karima Elshamy Faculty of Nursing Mansoura University Egypt
3 Learning Objectives: Define the following terminology chart, charting, patient record Discuss the purpose of the patient record List principles of charting. Identify contents of patient's hospital record List symptoms that require reporting Discuss descriptive terms commonly used in charting
4 Report: Is oral, written, or computer- based communication intended to convey information to others.
5 Reporting Oral or written Change of shift Nurse to nurse Promotes continuity Report on client health status, care required for next shift, significant facts, head to toe assessment, pertinent labs, priority needs, treatments, family issues
6 Patient's Record or Chart: Is an account of the patient's health history, current health status, treatment and progress. It is a formal, legal document that provides evidence of a client s care. Reporting and recording are the major communication techniques used by health care providers.
7 Purposes of Client's Record: Communication: Patient's record serves as the vechile by which different members of the health team communicate and share information with each other. Assessment: Nurses and other team members gather assessment data from the patient's record.
8 Planning Patient Care: The entire health team uses data from the patient's record to plan care for the patient. Education: Nursing students, medical students and other health team members often use patient records as educational tools. It provides a comprehensive view of the patient's health status.
9 Research: The information contained in a record can be a valuable source of data for research. Legal Documentation: It serves as a legal document of the patient's health status and the care given.
10 Statistics: Statistical information from patients' record can help an agency to anticipate and plan for people's future needs. Auditing: Patient's record is used to monitor the care received by the patient and the competence of people giving that care.
11 Principles Of Good Charting Include: Conciseness: Write concise and brief information. Use abbreviation only accepted and approved by all Use scientific terminology. Write in descriptive terms e.g. generalized pallor. Write meaningful statement.
12 Accuracy: Write only observation that he or she has seen, heard, smelled or felt. Use correct spelling and grammar. Correct use of medical terms. Write complete sentences. Precise measurements and time should be used as possible e.g. wounds should be described as 3cm by 0.5cm rather than small.
13 Completeness: The following information is essential when charting: Any new or changed information. Any signs and symptoms. Any nursing interventions. Medications given. Physician's orders. Patient teaching. Patient responses.
14 Organization: Information is grouped by problem or occurrence and flows in a logical format e.g. assessment is recorded with subjective data nursing intervention and patient's response. Start every entry with the date and time. Chart in a timely fashion to avoid omissions. Chart medications immediately after administration. Sign your name after each entry.
15 Legibility: Clear and easily read by others (readable). Write in ink. Use printing letter,
16 Timeline: Documentation should occur in a timely manner to: Avoid errors. Avoid forgetting important information. Protect the nurse from negligence or mal practice
17 Confidentiality: Never leave patient's chart in public area or where it could be read by unauthorized individual. Its content should not be discussed or shared involved in patient's care.
18 Documenting a Medication Error Document in the nurses progress notes: Name and dosage of the medication Name of the practitioner who was notified of the error Time of the notification Nursing interventions or medical treatment Client s response to treatment
19 Principles of Effective Documentation Elements of nursing process needed to be made evident in documentation include: Assessment. Nursing Diagnosis. Planning and outcome identification. Implementation. Evaluation. Revisions of planned care.
20 Contents of Patient's Record: Admission sheet: It contains client's name, address age, sex occupation, employee, religion, data and hour of admission, phone condition upon admission e.g. conscious, unconscious, ambulance brought by ambulance and history of previous hospitalization. The admission records also contain a list of patient's belonging upon admission.
21 Medical history and physical examination sheet: Filled by attendant physician, it summarizes vital signs upon admission, condition of heart, lungs, chest, abdomen, level of consciousness, presence of burns, vomitus, bleeding, summary of client's medical history, preliminary diagnosis, and tentative plan of care and signature of attendant physician.
22 Physician's order sheet: It contains specific order for medication, treatment diagnostic tests, diet, x-ray, and referral to other specialties.
23 Graph/ flow sheet: Include temperature, pulse, respiration, blood pressure, daily weight, intake and output measurements, urine sugar and acetone, daily activity, routine treatments performed.
24 Medication sheet: Contains name, dosage, route and time of medication given with initials and signature of nurse who gave it.
25 Physician's progress notes: Contain assessment and interpretation of client's progress with revisions of plan care.
26 Nurse's notes: Contain ongoing assessment, nursing diagnosis, outcome criteria, planning, intervention and evaluation of care. The nurse's notes supplies the following information: Drug administration Treatment applied. Nursing care given.
27 Fluid intake and output record. Routine care. Specific care measure e.g. scheduled deep breathing exercises, scheduled tube suctioning. Description of patient's reaction to therapy e.g. in case of I.V. infusion or enema. Description of physical and emotional signs and symptoms. Recording of unusual manifestation e.g. fever, dyspnea, bradycardia.
28 Miscellaneous forms: Include laboratory reports, x-ray reports consultations, respiratory therapy notes, physical therapy notes, social service notes. Discharge sheet: Contains physician's summary of patient's course of illness, response to treatment, prognosis status at discharge and plan for rehabilitation or follow up. Informed consent.
29 Informed Consent A competent client s ability to make health care decisions based on full disclosure of the benefits, risks, and potential consequences of a recommended treatment plan. The client s agreement to the treatment as indicated by the client s signing a consent form.
30 Methods of Documentation Narrative Charting Source-oriented charting Problem-oriented charting PIE charting Focus charting Charting by exception Computerized documentation Critical pathways
31 Narrative Charting This traditional method of nursing documentation takes the form of a story written in paragraphs. Before the advent of flow sheets, this was the only method for documenting care.
32 Source-Oriented Charting A narrative recording by each member (source) of the health care team on separate records.
33 Problem-Oriented Charting Focuses on the client s problem and employs a structured, logical format called SOAP charting: S: Subjective data (what the client states) O: Objective data (what is observed/inspected) A: Assessment P: Plan
34 PIE Charting P I E Problem Intervention Evaluation
35 Focus Charting A documentation method that uses a column format to chart data, action, and response (DAR). D A R Data, Action, and Response
36 Charting by Exception (CBE) A documentation method that requires the nurse to document only deviations from pre-established norms.
37 Computerized Documentation: Advantages Decreased documentation time. Increased legibility and accuracy. Clear and concise words. Statistical analysis of data. Enhanced implementation of the nursing process. Enhanced decision making. Multidisciplinary networking.
38 Point-of-Care System A handheld portable computer is used for inputting and retrieving client data at the bedside. Provides each health care practitioner with all pertinent client data to ensure continuity of care without duplication. Provides crucial client information in a timely fashion.
39 Case Management Process A methodology for organizing client care through an illness, using a critical pathway. A critical pathway is a monitoring and documentation tool used to ensure that interventions are performed on time and that client outcomes are achieved on time.
40 Forms for Recording Data Kardex Flow Sheets Nurse s Progress Notes Discharge Summary
41 Kardex A summary worksheet reference of basic information that traditionally is not part of the record, usually contains: Client data (name, age, marital status, religious preference, physician, family contact). Medical diagnoses: listed by priority. Allergies. Medical orders (diet, IV therapy, etc.). Activities permitted.
42 Flow Sheets Vertical or horizontal columns for recording dates and times and related assessment and intervention information. Also included are notes on: Client teaching. Use of special equipment. IV Therapy.
43 Nurse s Progress Notes Used to document: Client s condition, problems, and complaints. Interventions. Client s response to interventions. Achievement of outcomes.
44 Discharge Summary Highlights client s illness and course of care. Includes: Client s status at admission and discharge. Brief summary of client s care. Intervention and education outcomes. Resolved problems and continuing care needs. Client instructions regarding medications, diet, food-drug interactions, activity, treatments, follow-up and other special needs.
Documentation Objectives Define the documentation concept Discuss the purpose of documentation in the patient record. Describe factors that impact on documentation. Discuss the "who, what, when, where,
CHAPTER 6 Documentation 1 Slide 1 Purposes of Patient Records Five Basic Purposes for Written Records Written communication Permanent record for accountability Legal record of care Teaching Research and
TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER c: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE SECTION 300.1810 RESIDENT RECORD REQUIREMENTS
HIPAA Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice
B. Clinical Data Management The purpose of the applications of this group is to support the clinical needs of care providers including maintaining accurate medical records. Ideally, a clinical data management
CHAPTER 36 Interviewing the Patient, Taking a History, and Documentation Learning Outcomes 36.1 Identify the skills necessary to conduct a patient interview. 36.2 Implement the procedure for conducting
Medical Information Systems Introduction The introduction of information systems in hospitals and other medical facilities is not only driven by the wish to improve management of patient-related data for
Medical Record Documentation Standards Medical Record Documentation Standards and Performance Measures Compliance with the Standards is monitored as part of our Quality Improvement Program. Practitioner
POLICY and PROCEDURE TITLE: Documentation Requirements for the Medical Record Number: 13289 Version: 13289.1 Type: Administrative - Medical Staff Author: Joan Siler Effective Date: 8/16/2011 Original Date:
Guideline: In ICFs/MR, information reflecting the nursing plan of care as well as other pertinent information should be documented in the individual s record in an accurate, timely, and legible manner.
Special Topics in Vendor- Specific Systems Unit 4 EHR Functionality EHR functionality Results Review Outline Computerized Provider Order Entry (CPOE) Documentation Billing Messaging 2 Results Review Laboratory
North Shore LIJ Health System, Inc. Facility Name POLICY TITLE: The Medical Record POLICY #: 200.10 Approval Date: 2/14/13 Effective Date: Prepared by: Elizabeth Lotito, HIM Project Manager ADMINISTRATIVE
Chapter Eight Maintaining Health Records Maintaining the health records of children in foster care is critical to providing and monitoring health care on an ongoing basis. When health records are maintained
0BCHAPTER 15 F 1BI. POLICY The California Department of Corrections and Rehabilitation (CDCR) shall maintain s (CTC) to house inmate-patients who do not require general acute care level of services but
Location Hours 2 nd Floor CS&E Building A current UMHS identification badge is required to obtain medical records The Health Information Services Department is open to the public Monday through Friday,
What you should know about Data Quality A guide for health and social care staff Please note the scope of this document is to provide a broad overview of data quality issues around personal health information
Health Care Decision Making Worksheet Instructions Use this worksheet either to indicate current treatment preferences (which will be reflected in Maryland MOLST orders) or to clarify wishes for future
Community Caregivers Diseases of the Elderly/Vital Signs Test Name: Date: For each question, choose the best response or responses. 1. Care for a client with a stroke involves which of the following? a.
JOB DESCRIPTION NURSE PRACTITIONER Related documents: Nurse Practitioner Process Protocol Authorization for Individuals to Provide Services as Allied Health Personnel in the LPCH/SCH Administrative Manual
Medical Records Training Manual for EMR ENTERPRISE MEDICAL RECORD (EMR) The MEDITECH Enterprise Medical Record (EMR) collects, stores, and displays clinical data such as lab results, transcribed reports,
Family Caregiver Guide Emergency Room (ER) Visits: A Family Caregiver s Guide Your family member may someday have a medical emergency and need to go to a hospital Emergency Room (ER), which is also called
Medical Records Analysis Karen A. Mulroy, Partner Evans & Dixon, L.L.C. The analysis of medical legal issues posed in any case can be complicated, requiring some close reading and detective work to both
Facilitating A Learning Environment Expectations of Students, Faculty, and Staff Nurses In Acute and Residential settings In order to promote a supportive, effective learning environment, we have developed
Health Science Career Field Allied Health and Nursing Pathway (JM) ODE Courses Possible Sinclair Courses CTAG Courses for approved programs Health Science and Technology 1 st course in the Career Field
Professional Practice Medical Record Documentation Guidelines INTRODUCTION Consistent and complete documentation in the medical record is an essential component of quality patient care. All Participating
Clinical Staff Executive Committee MEDICAL CENTER POLICY NO. 0094 A. SUBJECT: Documentation of Patient Care (Electronic Medical Record) B. EFFECTIVE DATE: April 1, 2012 (R) C. POLICY: The University of
VN: Objective 01 EXPECTED CLINICAL ROTATION PERFORMANCE GUIDELINES Clinical rotation expected performances are reflected in the clinical objectives. Clinical objectives are posted by instructor at each
1 The Integrating Family Medicine and Pharmacy to Advance Primary Care Therapeutics (IMPACT) Clinical Documentation Guidelines Rationale Appropriate documentation of pharmaceutical care activities results
S OF CARE Oakland Transitional Grant Area Care and Treatment Services O CTOBER 2007 Office of AIDS Administration 1000 Broadway, Suite 310 Oakland, CA 94607 Tel: (510) 268-7630 Fax: (510) 268-7631 AREAS
Component 2: The Culture of Health Care Unit 3: Health Care Settings The Places Where Care Is Delivered Lecture 5 This material was developed by Oregon Health & Science University, funded by the Department
MOUNT SINAI HOSPITAL MEDICAL CENTER MEDITECH TRAINING This orientation manual is designed to ensure all per diem and contract agency personnel receive an orientation to Meditech prior to working at Mount
Collaborative Practice Agreement for Nurse Practitioner Management of Patients in the Specialty of Pediatric Critical Care Purpose Section I Introduction/Overview This document authorizes the nurse practitioner
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
INSTRUCTION FOR FORM PCF03: REQUEST FOR REHAB EXTENSION NOTE: Fields 5 MUST be filled in and you must attach a completed P.C. F0. Any incomplete form WILL BE REJECTED. Enter the assigned Pre-Certification
ALASKA Downloaded January 2011 7 AAC 12.255. SERVICES REQUIRED A nursing facility must provide nursing, pharmaceutical, either physical or occupational therapy, social work services, therapeutic recreational
The Changing Landscape and J a r r o d M a l o n e, J D firstname.lastname@example.org WHAT WE WILL TALK ABOUT TODAY Medical and legal issues for physicians best practices Reducing liability Medical Malpractice
group insurance Critical Illness Claim Form A partner you can trust. critical illness CLAIM FORM Policyholder s statement PLEASE PRINT. TO SPEED UP PROCESSING, ANSWER ALL QUESTIONS. Policyholder s name
Tips and Strategies on Handoffs In 2007, the Handoffs & Transitions Learning Network (H&T) was established to support the mid-atlantic healthcare community in tackling the complex problem of handoffs and
TUBERCULOSIS (TB) SCREENING GUIDELINES FOR RESIDENTIAL FACILITIES AND DRUG Tx CENTERS Tuberculosis Control Program Health and Human Services Agency San Diego County INTRODUCTION Reducing TB disease requires
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas
1 CPT AUDIT TOOL INSTRUCTIONS The Nursing Consultants from the Public Health Nursing and Professional Development Unit based on multiple Evaluation & Management audits across the state have developed these
1 Secondary Task List 100 INTRODUCTION TO HEALTHCARE 101 Identify the roles and educational/credentialing requirements of various health care practitioners. 102 Describe the 's job description, personal
Interfacility Transfer Guidelines for Children Dear Hospital CEO: As you may know, recent evidence shows that the best outcomes for critically ill and injured children are achieved when treated at facilities
MERCER COUNTY COMMUNITY COLLEGE DIVISION OF SCIENCE AND HEALTH PROFESSIONS NURSING PROGRAM NRS240 TRANSITION TO NURSING PRACTICE FALL 2013 HANDBOOK FOR RN PRECEPTORS AND STUDENTS Coordinator: Barbara A.
Page 1 of 21 GENERAL PATIENT UNIT When assigned to the General Patient unit paramedic student should gain knowledge and experience in the following: 1. Appropriate communication with patients and members
ION A Curriculum, Competencies and Externship MA.A.1. The depth and breadth of the program s curriculum enables graduates to acquire the knowledge and competencies necessary to become an entry-level professional
DOCUMENTATION FOR LICENSED NURSES Introduction Documentation for licensed nurses in our Center is an important aspect of providing care to our residents. Medical records are not only used as an important
National Health Care Foundation Standards and Accountability Criteria NCHSE-2012 This document describes the correlation between curriculum, supplied by Applied Educational Systems, and the National Health
TI 15.11.01 Appendix D 4/03 Page 1 of 8 HEALTH SERVICES UNIT ORIENTATION A. SICK CALL 1. Sick call is to be available to all inmates five days per week. 2. Sick call provides access for requested medical
XXX DAYTONA XXX _OCEANSIDE HEALTH CARE PARTNERS Department: Page 1 of 5 POLICY & PROCEDURE Policy Number NURSING 500.105 Effective Date Title: 6/12 SCOPE OF PRACTICE FOR STUDENT NURSES AND NURSING ASSISTANTS
STATE OF NEVADA Department of Administration Division of Human Resource Management CLASS SPECIFICATION TITLE GRADE EEO-4 CODE LICENSED PRACTICAL NURSE III 33* C 10.364 LICENSED PRACTICAL NURSE II 31* C
FOR THE ADVANCEMENT OF SCIENCE AND ART Dear Incoming Student: It is mandatory that you complete and return the enclosed Cooper Union health forms and the New York State required response forms for Meningitis,
FOR IMMEDIATE RELEASE REPORT OF FINDINGS LEXINGTON OF ORLAND PARK- 14-040-9001 HUMAN RIGHTS AUTHORITY- South Suburban Region [Case Summary The Authority did not substantiate the complaint below. The public
OASIS ITEM (M2200) Therapy Need: In the home health plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits (total
L I C E N S E D P R AC T I C AL N U R S E Schematic Code 14100 (30018654) I. DESCRIPTION OF WORK Positions in this banded class provide routine practical nursing work in the care and treatment of patients,
59A-4.150 Geriatric Outpatient Nurse Clinic. (1) Definitions: (a) Advanced Registered Nurse Practitioner a person who holds a current active license to practice professional nursing and a current Advanced
Medical Assisting I. Perform general office procedures to accreditation and certification standards recognized by the Each number refers to a single candidate (1-10). Place check ( ) in respective column
OASIS ITEM (M2200) Therapy Need: In the home health plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits (total
Documentation of Medical Records Records Introduction: In a continuous care operation, it is critical to document each patient s condition and history of care. To ensure the patient receives the best available
Procedure for Inotrope Administration in the home Purpose This purpose of this procedure is to define the care used when administering inotropic agents intravenously in the home This includes: A. Practice
Mona Osman MD, MPH, MBA Objectives To define an Electronic Medical Record (EMR) To demonstrate the benefits of EMR To introduce the Lebanese Society of Family Medicine- EMR Reality Check The healthcare
1 Secondary Task List 100 PHARMACOLOGY 101 Measure drug dosages using droppers, medicine cups, syringes, and other specialized devices. 102 Utilize correct technique to administer medications using the
HOSPITAL NAME INSTITUTIONAL POLICY AND PROCEDURE (IPP) Department: Manual: Section: TITLE/DESCRIPTION INTERDISCIPLINARY ASSESSMENT AND REASSESSMENT OF PATIENTS POLICY NUMBER EFFECTIVE DATE REVIEW DUE REPLACES
4658.00 (GENERAL) MINNESOTA Downloaded January 2011 4658.0015 COMPLIANCE WITH REGULATIONS AND STANDARDS. A nursing home must operate and provide services in compliance with all applicable federal, state,
Community Plan KanCare Program Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide Doc#: PCA15026_20141201 UHCCommunityPlan.com Welcome to UnitedHealthcare This administrative
Clinical Faculty Evaluation Form (Midterm/Final) NUR 680: Primary Care of Adults, NUR 682: Primary Care of Children, NUR 684: Primary Care of Women, NUR 672: Practicum The clinical evaluation tools for
Worker s Compensation Intake Form Patient Information: Name Home Phone Address Work Phone Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status Employer No of Children
Summary: CH CONSCIOUS SEDATION It is the policy of Carondelet Health that moderate conscious sedation of patients will be undertaken with appropriate evaluation and monitoring. Effective Date: 9/4/04 Revision
MERCER COUNTY COMMUNITY COLLEGE DIVISION OF MATH, SCIENCE AND HEALTH PROFESSIONS NURSING EDUCATION PROGRAM NRS240 TRANSITION TO NURSING PRACTICE SPRING 2016 HANDBOOK FOR RN PRECEPTORS AND STUDENTS TABLE
Barbara Hansen, MS, RN, LNCC, CPHRM Copyright 2015 by The Medical Resource Network, Inc. I have no known conflicts of interest. The presentation presents only hypothetical situations. I am not a lawyer
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
Student Name: SS#: Semester/ Year: Clinical Site: Lehman College Department of Nursing Clinical Evaluation Form Nursing 303 S = Satisfactory U = Unsatisfactory NO = Not Observed Final Grade: 1. Communication:
EMERGENCY MEDICINE PATIENT PRESENTATIONS: A How-To Guide For Medical Students Kerry B. Broderick, MD David E. Manthey, MD Wendy C. Coates, MD For the SAEM Undergraduate Education Committee Patient presentation
Write it Right! Kimberli M. P. Smart, RN, CPHRM Attorney COURSE OBJECTIVES Purposes of documentation; Impact on regulatory requirements, reimbursement and litigation; List 3 charting tips to assure documentation
Sonoma State University Department of Nursing Family Nurse Practitioner Program OB Preceptor Packet N550ABC Rev 8/05 WAS Department of Nursing 1801 East Cotati Avenue, Rohnert Park, California 94928-3609
IN-HOME QUALITY IMPROVEMENT BEST PRACTICE: PHYSICIAN RELATIONSHIPS NURSE TRACK Best Practice Intervention Packages were designed for use by any In-Home Provider Agency to support reducing avoidable hospitalizations
LICENSED PRACTICAL NURSE (LPN) JOB SUMMARY AND PERFORMANCE CRITERIA (See full job description for physical demands) Department Assigned: Nursing Supervisor Title: Registered Nurse Purpose of Your Job Position
WEEK BY WEEK GUIDE TO CLINICAL PROGRESS IN PRECEPTORSHIP 1 During your first discussion with your preceptor, the following topics may be useful: Decide on the starting date and shift for your first clinical
MEDICAL MUTUAL Self-Assessment Form PURPOSE: The purpose of the self-assessment form is to highlight those areas within the non-clinical aspect of office practice including documentation of medical records,
CONNECTICUT Statewide Career & Technical Education ASSESSMENT State Department of Education Academic Office 165 Capital Avenue - Room 205 Hartford, Connecticut 06106 860-713-6764 2015 Medical Careers Education