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Documentation

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Not charting correct time events occurred. Failing to record ... Charting Bloopers. Skin: Somewhat pale but present. The pelvic exam will be done on the floor. ... – PowerPoint PPT presentation

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Title: Documentation


1
Documentation
  • NUR 869

2
Client Record
  • A permanent legal documentation of information
    relevant to clients health care management.

3
Purpose of the record
  • Communication between team members
  • Financial Billing
  • Education
  • Assessment
  • Research
  • Auditing
  • Legal Documentation

4
  • CARE NOT
  • DOCUMENTED IS CARE NOT DONE.

5
Common problems in malpractice
  1. Not charting correct time events occurred
  2. Failing to record verbal orders or have them
    signed
  3. Charting in advance to save time
  4. Documenting incorrect data

6
  • We are legally and ethically obligated to keep
    client information confidential.

7
  • The client can read records with written release
    of information.

8
Components of client record
  • 1. Information sheet
  • 2. Graphic sheet
  • 3. Physicians order sheet
  • 4. Progress notes
  • 5. Flow sheets
  • 6. Consult sheet
  • 7. Laboratory results
  • 8. Consent Form
  • 9. Medication Records
  • 10.Special Records
  • 11.Discharge Summary

9
Guidelines for documentation and reporting
  • Factual
  • Accurate
  • Complete
  • Current
  • Organized
  • Confidentiality

10
  • CONFIDENTIALITY

11
Methods of Documentation
  • SOAP notes
  • DAR

12
Charting Bloopers
  • Skin Somewhat pale but present.
  • The pelvic exam will be done on the floor.
  • She was treated with Mycostatin oral
    suppositories.
  • By the time she was admitted to the hospital her
    rapid heart had stopped and she was feeling much
    better.
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